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

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service September 
20, 2022. 
 You asked the Plan to pay for procedure code 76642. You say that the claim was billed correctly and should be 
paid. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service September 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675). 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was medically 
necessary. The Plan denied your request. The Plan says this equipment was used outside the home and is non-
covered. 
 
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 is for use outside of the home. 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 a pneumatic compression device (E0673, E0675).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home infusion services. 
 
You asked the Plan to pay for the home infusion services. You say to please review and process the claim 
accordingly for correct payment.  The Plan denied your request. The Plan says that the enrollee's plan excludes 
this service. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must provide reimbursement for all plan-
covered medically necessary services received from non-contracted providers without prior authorization 
requirements.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home infusion services have been met. Specifically, the Plan did not provide medical records 
for review or have substantiated their reason for the denial. Therefore, we decided that the Plan has to pay for 
home infusion services.  
 
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 pay for procedure code 70450 billed for date of service October 27, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. 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 October 27, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a OneTouch Delica Plus Lancet provided on December 27, 
2022. 
 
You asked the Plan to pay for diabetic supplies. You say that you need these supplies. The Plan denied your 
request. The Plan says a prescription for the rendered diabetic supplies was never received. 
 
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 valid physician order. A valid physician order is required. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided 
that the Plan does not have to pay for a OneTouch Delica Plus Lancet provided on December 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for Limited Oral Evaluation - Problem Focused (code 
D0140), Intraoral - Periapical First Radiographic Image (code D0220), Bitewing - Single Radiographic Image 
(code D0270) and Intraoral -Periapical Each Additional Image (code D0230) provided on September 14, 2022. 
 
You asked the Plan to pay more for the dental services. The Plan denied your request. The Plan says you are 
responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider. 
 
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. 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for Limited Oral Evaluation - Problem Focused 
(code D0140), Intraoral - Periapical First Radiographic Image (code D0220), Bitewing - Single Radiographic 
Image (code D0270) and Intraoral -Periapical Each Additional Image (code D0230) provided on 
September 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services (procedure codes 93922 and 93924) rendered 
on September 19, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 the denied codes is: 
 
CPT 93922: 
 
Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (eg, for lower extremity: 
ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, 
Doppler waveform recording and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tibial and 
anterior tibial/dorsalis pedis arteries plus volume plethysmography at 1-2 levels, or ankle/brachial indices at 
distal posterior tibial and anterior tibial/dorsalis pedis arteries with, transcutaneous oxygen tension 
measurement at 1-2 levels) 
 
CPT 93924: 
 
Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, (ie, 
bidirectional Doppler waveform or volume plethysmography recording and analysis at rest with ankle/brachial 
indices immediately after and at timed intervals following performance of a standardized protocol on a 
motorized treadmill plus recording of time of onset of claudication or other symptoms, maximal walking time, 
and time to recovery) complete bilateral study 
 
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 services at issue in 
this case were not supported. Our reviewer found that CPT 93924 is for evaluation both before and after 
treadmill testing including oxygenation. The report does not clearly specify the pre and post treadmill analysis 
and should be denied. 
 
Additionally, there is an edit between CPT 93922 and CPT 93924. CPT 93922 is a column II code to the 
column I code 93924. As the records do not support the use of the comprehensive CPT 93924, the lesser code 
also is not supported. 
 
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 testing services (procedure codes 93922 and 93924) rendered on September 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation - per site 
(D7953) provided on October 19, 2022. 
 
You asked the Plan to pay for the bone replacement graft for ridge preservation. You say that the bone in your 
jaw is important for eating and is part of your structure. The Plan denied your request. The Plan says this 
service 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 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 a bone 
replacement graft for ridge preservation - per site (D7953) provided on October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (64490, 64491, J1040) provided on September 27, 
2022. 
 
You asked the Plan to pay for the injections. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the records do not support the billed services. 
 
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 codes 64490, 64491 and J1040 are not supported in the medical record. Specifically, the 
codes billed were billed using the RT (right) modifier, however, records provided show this procedure was 
performed on the left. Based on this information, we decided that Medicare rules for coverage of the injections 
have not been met. Therefore, we decided that the Plan does not have to pay for injections (64490, 64491, 
J1040) provided on September 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
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 Durolane 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 that the enrollee has primary osteoarthritis of bilateral shoulders and severe bilateral shoulder rotator cuff arhtropathy. He received a single 
shot of Durolane on September 1, 2022 into the glenohumeral joints of both sohoulders. The labeling states that 
Durolane is indicated for the treatment of pain in osteoarthritis (OA) of the knee in patients who have failed to 
respond adequately to conservative non-pharmacological therapy or simple analgesics, e.g. acetaminophen. The 
Durolane is not reasonable or medically necessary for the enrollee's diagnosis. 
 
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 Durolane.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions, of an erupted tooth requiring removal of 
bone and/or sectioning of tooth (D7210 x 2), deep sedation/general anesthesia first 15 minutes (D9222), deep 
sedation/general anesthesiaeach subsequent 15 minute increment (D9223 x 3), the therapeutic parenteral drug, 
single administration (D9610), and the unspecified adjunctive procedures, by report (D9999 x 2) provided on 
August 26, 2022. 
 You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the items/services provided are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
extractions, of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210 x 2), deep 
sedation/general anesthesia first 15 minutes (D9222), deep sedation/general anesthesiaeach subsequent 15 
minute increment (D9223 x 3), the therapeutic parenteral drug, single administration (D9610), and the 
unspecified adjunctive procedures, by report (D9999 x 2) provided on August 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics-porcelain fused to noble metal for teeth number 
6 and 10 (D6242 x 2) and a retainer crown-porcelain fused to noble metal for tooth number 11 (D6752). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says your benefit for the requested items has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested items has been exhausted. Specifically, the Plans contract states that up to 
four units of a fixed denture are covered per year.  The Plan previously approved coverage for four units of a fixed denture for teeth number 5, 7, 8, 9. Therefore, 
the benefit for the dental items requested in this case has been exhausted at this time. Therefore, we decided 
that the Plan does not have to pre-approve pontics-porcelain fused to noble metal for teeth number 6 and 10 
(D6242 x 2) and a retainer crown-porcelain fused to noble metal for tooth number 11 (D6752).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for 
date of service June 7, 2022. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, 88360 and 88381. You say that these services 
were medically necessary. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360 and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360 and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for date of service June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic exam (code D0120) and prophylaxis (code D1110) 
provided on December 15, 2022. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic exam (code D0120) and prophylaxis (code D1110) provided on December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
October 18, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract says that hearing aids are covered 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5298) purchased on October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service October 13, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service October 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 18, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950), pontics (D6245), retainer crowns 
(D6740), and the application of resin for root surface (D9911) for tooth #12, #13, and #14 provided on March 
23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told you had $1,500 for dental of any 
kind and you would like to be reimbursed. The Plan denied your request. The Plan says the denial of payment 
for these services is correct, because the core buildup, pontics, retainer crowns, and the application of resin for 
root surface are not covered by the Plan. 
 
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 the core 
buildup (D2950), pontics (D6245), retainer crowns (D6740), and the application of resin for root surface 
(D9911) for tooth #12, #13, and #14 provided on March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on November 29, 
2022. 
 
You asked the Plan to pay for the dental service. You say that both the dentist visits were for separate dental 
problems and the Plan should cover both visits. The Plan denied your request. The Plan says your benefit for 
the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of November 10, 
2022. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided 
on November 29, 2022.