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

 
We decided that the Plan has to pay for the laboratory services coded as 88341, 88342, 88360 and 88381 
provided March 1, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee has been diagnosed with cancer 
and therefore, the enrollee's physician has ordered molecular testing from Caris as part of the treatment plan. 
The Plan denied your request. The Plan says that the provider did not bill as required by Medicare coding 
regulations. 
 
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 
codes 88341 is immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody 
stain procedure (list separately in addition to code for primary procedure),  88342 is immunohistochemistry or 
immunocytochemistry, per specimen; initial single antibody stain procedure , 88360  is morphometric analysis, 
tumor immunohistochemistry (eg, her-2/neu, estrogen receptor/progesterone receptor), quantitative or 
semiquantitative, per specimen, each single antibody stain procedure; manual and 88381 is mmicrodissection 
(ie, sample preparation of microscopically identified target).  
 
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 laboratory services. Our reviewer says that the requested 
items/services are supported by the medical records in this case. Our reviewer found the lab results do support 
the use of procedure codes 88360-xu, 88342-xu, 88342-xu. Per coding guidelines modifier xu is not needed on 
88381, but the procedure code is correct. 
 
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 laboratory services have been met. Therefore, we decided that the Plan has 
to pay for the laboratory services coded as 88341, 88342, 88360 and 88381 provided March 1, 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: ER
Decision: Favorable

 
We decided that the Plan has to pay for a catheter insertion (36556) provided on September 4, 2022. 
 
You asked the Plan to pay for a catheter insertion. You say that this was billed correctly. The Plan denied your 
request. The Plan says that this code 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 36556 is insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older 
(Insertion of catheter in vein for infusion). 
 
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 a catheter insertion. Our reviewer says that the use of code 
36556 is supported. Our reviewer found the submitted medical records include the description of the insertion 
of central line. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a catheter insertion have been met. Therefore, we decided that the Plan has to 
pay for a catheter insertion (36556) provided on September 4, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service December 
28, 2021. 
 
You asked the Plan to pay for procedure code 87634. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 87634 is bundled into payment for code 87632. 
 
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 87634 
is a column II code to column I code 87632. 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 87634 billed for date of service December 28, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 Grafix skin substitute applications. 
 
You asked the Plan to pre-approve 3 Grafix skin substitute applications. 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. 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 3 Grafix skin substitute applications. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found 7 applications of Grafix Prime skin substitute have been authorized by the health plan. This is certainly a reasonable and standard number of applications for ulceration healing. It is 
reasonable to assess whether additional applications need to be requested once the 7 applications have been 
applied and the ulcer has been assessed. Therefore, the remaining 3 applications of Grafix Prime skin substitute 
are not medically reasonable or necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3 Grafix skin substitute applications have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 3 Grafix skin substitute applications.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99233) provided from April 18, 2022, to April 
20, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit". 
 
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 99233 is 
not supported by the records provided. Our reviewer found that the documentation does not indicate that the 
enrollee was unstable or had developed any complications for the dates in question. 
 
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 (99233) provided from April 18, 2022, to April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that facet joint injections are medically 
necessary. The Plan denied your request. The Plan says the requested facet joint injections do not meet the 
Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 facet joint injections. Our reviewer says 
that the requested facet joint injections are not medically necessary. Our physician reviewer found that 
according to the limitations on facet joint procedures, facet joint interventions done without CT or fluoroscopic 
guidance are considered not reasonable and necessary. This includes facet joint interventions done without any 
guidance, performed under ultrasound guidance, or with magnetic resonance imaging (MRI). In this case, since 
the provider is requesting the above noted facet joint interventions to be done without CT or fluoroscopic 
guidance, these services are considered not reasonable or necessary. The review has determined that the 
requested facet joint injections do not meet the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Medtronic BMP Infuse allograft (20930) and 
bone marrow aspirate (20939) for spinal surgery. 
 
You asked the Plan to pre-approve Medtronic BMP Infuse allograft and bone marrow aspirate. 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 Medtronic BMP Infuse allograft and 
bone marrow aspirate. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested services are experimental in the 
posterior lumbar spine. More research is needed to demonstrate the safety and efficacy of the requested 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Medtronic BMP Infuse allograft and bone marrow aspirate have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the use of Medtronic BMP Infuse allograft 
(20930) and bone marrow aspirate (20939) for spinal surgery.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve pontics (6245) for tooth #13 and #14. We decided that the Plan 
does not have to pre-approve custom fabricated abutment (D6057) and abutment support crown (D6058) for 
tooth #11 and #12.  
 
You asked the Plan to pre-approve a custom fabricated abutment (D6057), abutment support crown (D6058), 
and pontics (D6245) for tooth #11, #12, #13, #14. You say that you are appealing the denied dental services 
because they need to be completed and not individual. The Plan says that your benefit for the implants and 
pontics has been exhausted for the year. 
 
We decided that the Plan has to pre-approve pontics (6245) for tooth #13 and #14.  
 
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 limit of 4 pontics was previously exhausted. The 
Plan approved 2 pontics (D6245) for tooth #7 and #10. Therefore, we decided that the Plan has to pre-approve 
pontics (6245) for tooth #13 and #14.  
 
We also decided that the Plan does not have to pre-approve custom fabricated abutment (D6057) and 
abutment support crown (D6058) for tooth #11 and #12. 
 
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, certain limitations apply. The record 
shows the Plan approved a custom fabricated abutment (D6057) and abutment supported crown (D6058) for 
tooth #8 and #9; therefore, your benefit for implant services was exhausted on the date of approval of February 
6, 2023. Therefore, we decided that the Plan does not have to pre-approve custom fabricated abutment (D6057) 
and abutment support crown (D6058) for tooth #11 and #12. 
  
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: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the drug injections provided from October 6, 2022, 
to October 28, 2022. We also decided that the Plan does not have to waive the copayments for the inpatient 
hospital stay provided from September 5, 2022, to September 7, 2022, and the PICC line insertion provided on 
September 30, 2022. 
 
You asked the Plan to waive the cost share for the inpatient hospital stay, PICC line insertion, and drug 
injections. You say that these services should be fully covered. The Plan denied your request. The Plan says 
that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the coinsurance for the drug injections provided from October 6, 
2022, to October 28, 2022.  
 
You have been asked to pay 20% coinsurance for each injection. According to Medicare, the injections (J9181, 
J2405, J1100, J9045, J2469) that assessed cost share amounts are considered packaged codes and are not 
separately payable. These codes are also excluded from the physicians free schedule. According to Medicare, 
codes J9022 and J1453 are also excluded from the physicians fee schedule. Therefore, we decided that the 
Plan has to waive the coinsurance for the injections provided from October 6, 2022, to October 28, 2022.  
 
We also decided that the Plan does not have to waive the copayments for the inpatient hospital stay 
provided from September 5, 2022, to September 7, 2022, and the PICC line insertion provided on 
September 30, 2022. 
 
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 $400 
copayment per day for days 1-4 of each inpatient hospital stay. Your contract with the Plan also clearly says 
that you must pay a $300 copayment for outpatient surgery.  
 
You have been asked to pay $511.30 for the inpatient hospital stay. This is less than the standard cost share for 
inpatient hospital care due to you meeting your out-of-pocket maximum. These items/services fall within the 
inpatient hospital care benefit category. You have also been asked to pay a $300 copayment for the outpatient 
surgery. This item/service falls within the outpatient surgery benefit category. Therefore, we decided that the 
Plan does not have to waive the copayments for the inpatient hospital stay provided from September 5, 2022, to 
September 7, 2022, and the PICC line insertion provided on September 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service November 
14, 2022. 
 
You asked the Plan to pay for procedure code 81345. You say that this service was necessary and is supported 
in the medical records. The Plan denied your request. The Plan says payment for code 81345 is bundled into 
payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service November 14, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the photochromatic lens tint billed with code V2744 for 
October 18, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the KX modifier must be billed for procedure 
code V2744 when medical necessity is documented by the treating practitioner. 
 
We looked at the file and Medicare rules. The file shows that code V2744 was not billed with the required KX 
modifier. 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 photochromatic lens tint billed with 
code V2744 for October 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an odontoplasty (D9971 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you need the odontoplasty because of a 
hole in your tooth. It is sharp to the touch and cuts your tongue. The Plan denied your request. The Plan says 
this service is not a covered benefit under your dental plan. 
 
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 an 
odontoplasty (D9971 x 2).
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 November 3, 
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 November 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral hygiene instructions (D1330), the inhalation of 
nitrous oxide/analgesia (D9230), and the application of a desensitizing medicament (D9910). 
 
You asked the Plan to pre-approve these items/services. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says these items/services are not covered under your 
supplemental dental policy. 
 
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/services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve oral 
hygiene instructions (D1330), the inhalation of nitrous oxide/analgesia (D9230), and the application of a 
desensitizing medicament (D9910).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for PT visits provided from September 2, 
2022, to September 15, 2022. 
 
You asked the Plan to waive the copayments for PT services. You say that you disagree with the copayment 
charged for the PT visits. 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 $40 
copayment for each physical therapy visit.  
 
You have been asked to pay a $120 copayment for PT services ($40 per visit x 3 visits = $120). This 
item/service falls within the Outpatient Rehabilitation Service 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 copayments for PT visits provided from June 29, 2022, to September 15, 2022.