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

 
We decided that the Plan does not have to pay for a swallowing function x-ray (CPT 74230) and an upper 
gastrointestinal tract x-ray (CPT 74240) provided on August 18, 2022. 
 
You asked the Plan to pay for the swallowing function x-ray (CPT 74230) and an upper gastrointestinal tract  
x-ray (CPT 74240). You say that the services were medically necessary. The Plan denied your request. The 
Plan says the services were performed at a nursing home (via mobile van/portable x-ray), which are denied as 
an excluded place of service. 
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. The file shows that these services were performed at a nursing home 
(via mobile van/portable x-ray), which is an excluded place of service per the Medicare LCD coverage criteria. 
Based on this information, we decided that Medicare rules for coverage of a swallowing function x-ray  
(CPT 74230) and an upper gastrointestinal tract x-ray (CPT 74240) have not been met. Therefore, we decided 
that the Plan does not have to pay for a swallowing function x-ray (CPT 74230) and an upper gastrointestinal 
tract x-ray (CPT 74240)  provided on August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on November 14, 2022. 
 
You asked the Plan to pay for the limited oral evaluation (D0140). You say that the dentist could not do the 
procedure and suggested the tooth be pulled and replaced with an implant. You also say that your visit was for 
5 minutes. The Plan denied your request. The Plan says a limited oral evaluation - problem focused (D0140) is 
not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation - problem 
focused (D0140) is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for a limited oral evaluation - problem focused (D0140) provided on November 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vertebroplasty. 
 
You asked the Plan to pre-approve vertebroplasty. 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 percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures 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 vertebroplasty. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there are no acute or subacute T1 to L5 
fractures. The provider is requesting the procedure to treat chronic sacral insufficiency fractures. The review 
has determined that the enrollee does not meet the coverage criteria detailed in LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vertebroplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve vertebroplasty.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88189 billed for date of service July 13, 
2022. 
 
You asked the Plan to pay for procedure code 88189. You say that the modifier was on the other charges. The 
Plan denied your request. The Plan says payment for code 88189 is bundled into payment for code 88325. 
 
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 88189 is a column II code to column I code 88325. The code at issue 
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 
88189 billed for date of service July 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test, localized delivery of 
antimicrobial agents, and occlusal guard (D9944, D0431, D4381) provided on February 1, 2022, to August 19, 
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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
adjunctive pre-diagnostic test, localized delivery of antimicrobial agents, and occlusal guard (D9944, D0431, 
D4381) provided on February 1, 2022, to August 19, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for one additional unit of procedure code 93922. We decided that the 
Plan does not have to pay for the remaining two additional units of procedure code 93922.  
 
You asked the Plan to pay for procedure code 93922 provided on January 17, 2022.. You say that you would 
like the Plan to reconsider their denial of payment. The Plan says that the services are not covered as billed. 
 
We decided that the Plan has to pay for one additional unit of procedure code 93922.  
 
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 procedure code 93922 is 2. The MAI value for this code is 2. You billed 3 units of 
procedure code 93922 on the claim in dispute, exceeding the MUE. Based on this information, we decided that 
Medicare rules for coverage of 1 out of the 3 units of procedure code 93922 have been met. The file shows that 
the Plan paid for one unit of procedure code 93922 on February 17, 2022. As the MUE for this code is 2, 2 
units per date of service can be billed. Therefore, we find that the Plan has to pay 1 additional unit of procedure 
code 93922 out of the 3 units billed on the claim submitted on August 9, 2022.  
 
We also decided that the Plan does not have to pay for the remaining two additional units of procedure 
code 93922. 
 
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 procedure code 93922 is 2. The MAI value for this code is 2. You billed 3 units of 
procedure code 93922 on the claim in dispute, exceeding the MUE. Based on this information, we decided that 
Medicare rules for coverage of 2 out of the 3 units of procedure code 93922 have not been met. The file shows 
that the Plan paid for one unit of procedure code 93922 on February 17, 2022. As the MUE for this code is 2, 2 
units per date of service can be billed. We find that the Plan has to pay 1 additional unit of procedure code 
93922 out of the 3 units billed on the claim submitted on August 9, 2022. Therefore, we decided that the Plan 
does not have to pay for the remaining two additional units of procedure code 93922. 
 
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 copayments for the magnetic resonance imaging (MRI) 
scans provided from December 15, 2021, to November 1, 2022. 
 
You asked the Plan to waive the copayments for the MRIs. You say that you are being charged for additional 
services on these dates of service that should be bundled together. 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). The enrollees 2021 contract with the Plan clearly says that enrollees must pay a $275 copayment for each in-network complex radiology service, including MRIs. The 
enrollees 2022 contract with the Plan also clearly says that enrollees must pay a $300 copayment for each in-
network complex radiology service, including MRIs. 
 
The enrollee has been asked to pay a $275 copayment for the MRI provided on December 15, 2021. The 
enrollee has also been asked to pay a $300 copayment for each MRI provided on August 25, 2022, and 
November 1, 2022. These items/services fall within the outpatient diagnostic tests and therapeutic services 
benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract 
with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayments for the MRI scans provided from 
December 15, 2021, to November 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray study of swallowing function with contrast material 
(74230) and single contrast x-ray of upper digestive tract (74240) provided on August 31, 2022. 
 
You asked the Plan to pay for the x-ray study of swallowing function with contrast material and single contrast 
x-ray of upper digestive tract. You say that the x-ray study of swallowing function with contrast material and 
single contrast x-ray of upper digestive tract was medically necessary. The Plan denied your request. The Plan 
says these services are excluded from coverage when performed in a mobile setting. 
 
The Plan must follow Medicare rules. Medicare rules say that barium swallow studies will not be covered when 
performed in a mobile setting.  
 
We looked at the file and Medicare rules. The record shows that the barium studies were performed in a mobile 
setting at the skilled nursing facility where the enrollee is residing. Based on this information, we decided that 
Medicare rules for coverage of the x-ray study of swallowing function with contrast material and single 
contrast x-ray of upper digestive tract. have not been met. Therefore, we decided that the Plan does not have to 
pay for the x-ray study of swallowing function with contrast material (74230) and single contrast x-ray of upper 
digestive tract (74240) provided on August 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vitamin D testing (82306) and the HIV-1 and HIV-2 
testing (86703) provided on October 7, 2022. 
 
You asked the Plan to pay for the vitamin D testing and HIV-1 and HIV-2 testing. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this testing is not covered for screening 
purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the vitamin D testing and HIV-1 and HIV-2 testing, was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for the vitamin D testing (82306) and the HIV-1 and HIV-2 testing (86703) 
provided on October 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95937 provided on December 8, 2022. 
 
You asked the Plan to pay for procedure code 95937. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate 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 find that Train of Four Testing does not fit the criteria set by CMS for CPT 95937. There is no separate 
code for Train of Four Monitoring, therefore, it would be inappropriate to bill the neuromuscular junction 
testing code for Train of Four Monitoring. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 95937 provided on December 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the revascularization of the right iliac artery, right 
tibial/peroneal of the right leg (37221 and 37229). 
 
You asked the Plan to pre-approve the surgical services. You say that the surgical services are medically 
necessary. The Plan denied your request. The Plan says the surgical services are not medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgical services. Our physician 
reviewer found the documentation does not support coverage of the treatments in question. While there are 
inconsistencies in the medical record, there is documentation suggesting limb threatening ischemia of the left 
lower extremity. The assessment states that the patient has left lower extremity atherosclerosis with gangrene. 
Although not mentioned in the patient assessment, there is a noninvasive study suggesting the presence of a 
bypass in the left lower extremity. With respect to the right lower extremity, the ankle brachial index (ABI) is 
relatively normal and based on the enrollees history of limb threatening ischemia on the left and possible 
neuropathic pain as documented in the assessment, there is insufficient documentation on which to overturn the 
Health Plans determination with respect to the right leg. 
 
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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the revascularization of the right iliac artery, right tibial/peroneal of the right leg 
(37221 and 37229).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the footplate bracket assembly, upgraded enhanced 
joystick, hydration system, backup camera, proximity sensor, and drive custom knee adductor pad. 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the hydration system, backup camera, and proximity sensor do not 
primarily serve medical purposes. The joystick controller display, footplate bracket assembly, and drive custom 
knee adductor pad are already included in the approved wheelchair and cannot be unbundled. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  E1012 includes all components of the leg rest, including fixed angle footplates and foot 
platforms. 
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. The footplate is 
included in the power leg elevation feature (E1012) and not separately approvable. Therefore, we decided that 
the Plan does not have to pre-approve the footplate bracket assembly, upgraded enhanced joystick, hydration 
system, backup camera, proximity sensor, and drive custom knee adductor pad.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for a urine PCR (polymerase chain reaction) panel (87150, 87798, 87487, 
87801, 87640 and 87653) provided on November 23, 2022. 
 
You asked the Plan to pay for a urine PCR panel. You say that this testing was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says that this panel was not billed in 
accordance with Medicare guidelines. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan does not cite the rule used to deny payment of these 
services. We were unable to locate this information in a determination which applies to the state where these 
services were provided. The Plan has provided no other reason for denial of these services. The Plan's denial is 
not substantiated in this case. Therefore, we decided that the Plan has to pay for a urine PCR (polymerase chain 
reaction) panel (87150, 87798, 87487, 87801, 87640 and 87653) provided on November 23, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of pacing electrode, cardiac venous system, for 
left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (eg, for 
upgrade to dual chamber system) (List separately in addition to code for primary procedure) (33225). 
 
You asked the Plan to pre-approve the service. You say that this to help the heart function. The Plan denied 
your request. The Plan says the service is not necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our physician reviewer 
found there is no documentation of left ventricular dysfunction, as she has exhibited a normal ejection fraction 
on nuclear imaging. In summary, there is insufficient documentation to support the medical necessity for 
implantation of a bi-ventricular pacemaker. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of 
insertion of implantable defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system) 
(List separately in addition to code for primary procedure) (33225).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the hospital care. We decided that the Plan does not have to pay for 
the x-rays with contrast.  
 
You asked the Plan to pay for the initial hospital care (99222), x-ray of swallow function, with 
cineradiography/videoradiography, with contrast (74230), and x-ray of upper gastrointestinal tract, with 
contrast (74240) provided on November 9, 2022. You say that the fixed itinerant physician office on wheels 
was medically necessary because the care team documented a limitation to transporting the enrollee. The Plan 
says that the documentation does not reference a locum/covering physician. The Plan also says that x-rays with 
contrast are not covered when performed as a portable x-ray service. 
 
We decided that the Plan has to pay for the hospital care.  
 
The Plan follows Medicare rules. Medicare rules say that in indicate that the services were provided by a 
substitute physician or physical therapist under a fee-for-time compensation arrangement meeting the 
requirements of this section by entering HCPCS code modifier Q6 after the procedure code.  
 
The file shows that modifier Q6 was included on the claim. The rules do not require any more documentation 
than the modifier Q6 on the claim. Therefore, we decided that the Plan has to pay for the hospital care.  
 
We also decided that the Plan does not have to pay for the x-rays with contrast. 
 
The Plan follows Medicare rules. Medicare rules say that procedures and examinations which are not covered 
under the portable x-ray provision include procedures involving the use of contrast media. Therefore, we 
decided that the Plan does not have to pay for the x-rays with contrast. 
 
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 pay for procedure code 99100 billed for date of service October 18, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. 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 October 18, 2022.