Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the diabetic test strips (A4253). 
 
You asked the Plan to pre-approve the diabetic test strips. You say that the item should be covered. The Plan 
denied your request. The Plan says only the preferred brand products listed in the EOC are covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the diabetic test strips. Therefore, we decided that the Plan does not have to pre-approve the diabetic test 
strips (A4253).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays-four 
radiographic images (D0274), and the dental cleaning (D1110) provided on December 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. 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 dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the services provided 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 the periodic oral evaluation (D0120), bitewing  
x-rays-four radiographic images (D0274), and the dental cleaning (D1110) provided on December 12, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation (G0283) provided on September 6, 
2022. 
 You asked the Plan to pay for the electrical stimulation. The Plan denied your request. The Plan says this 
service does not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that the literature and scientific evidence supporting 
the use of peripheral nerve blocks with or without the use of electrostimulation, and the use of 
electrostimulation alone for neuropathies or peripheral neuropathies caused by underlying systemic diseases, is 
insufficient to warrant coverage. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the electrical stimulation have not been met. Therefore, we decided that the Plan does not have to 
pay for the electrical stimulation (G0283) provided on September 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73600 billed for date of service November 
18, 2022. 
 You asked the Plan to pay for procedure code 73600. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 73600 is bundled into payment for code 
73610. 
 
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 73600 
is a column II code to column I code 73610. 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 73600 billed for date of service November 18, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76942 and 93454 rendered from October 1, 
2022, to October 3, 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 76942: 
 
Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging 
supervision and interpretation 
 CPT 93454: 
 
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for 
coronary angiography, imaging supervision and interpretation 
 
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 by the medical records. Our reviewer found that the use of CPT 76942 to 
document the use of ultrasound for vascular access is inappropriate. The use of this code is for supervision and 
interpretation, not for catheter placement. The use of CPT 93454 is inappropriate and would be considered to 
be inclusive to CPT 92086. 
 
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 procedure codes 76942 and 93454 rendered from October 1, 2022, to October 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service August 4, 
2022. 
 You asked the Plan to pay for procedure code 93010. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 93010 is bundled into payment for code 
93280. 
 
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 93010 
is a column II code to column I code 93280. 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 93010 billed for date of service August 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) rendered 
from June 24, 2022, to June 27, 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 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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the review has determined 
that the records did not support 2 of the 3 key components for this code. The medical records submitted did not 
support a detailed interval history and medical decision making of high complexity. 
 
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 subsequent hospital care (procedure code 99233) rendered from June 24, 2022, to June 27, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick Catheter system (K1006). 
 
You asked the Plan to pre-approve Purewick Catheter system. You say that the enrollee needs this item to 
prevent skin break down. The Plan denied your request. The Plan says the requested item is not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
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. Therefore, we 
decided that the Plan does not have to pre-approve a Purewick Catheter system (K1006).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for angiography services (procedure code 75726, 75774) rendered on 
August 6, 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 that 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 75726: 
 
Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision 
and interpretation 
 
CPT 75774: 
 
Angiography, selective, each additional vessel studied after basic examination, radiological supervision and 
interpretation (List separately in addition to code for primary procedure) 
 
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 supported by the medical records. Our reviewer found that the documentation supports coverage 
of the codes in question. Diagnostic angiography performed prior to embolization in order to localize the area 
of concern is separately billable and not bundled in the embolization code. There is satisfactory documentation 
of the results of a celiac angiogram, justifying use of code 75726. There is a repositioning of the catheter to the 
gastroduodenal artery and satisfactory documentation of findings justifying the use of the add-on code 75774. 
There is an additional reposition to a subbranch of the gastroduodenal artery (GDA) with satisfactory 
documentation of the findings including the extravasation and therefore a second instance of 75774 is 
appropriate.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
angiography services (procedure code 75726, 75774) rendered on August 6, 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 pay for initial observation care (procedure code 99220) rendered on 
July 21, 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 Current Procedural Terminology (CPT) 99220 remains 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 99220 is "Initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and 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 problem(s) requiring 
admission to outpatient hospital "observation status" are of high severity. Typically, 70 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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the records supported a 
comprehensive history and a comprehensive examination but not medical decision making of high complexity. 
 
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 initial observation care (procedure code 99220) rendered on July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care (procedure codes 99220 and 99225) 
rendered from May 26, 2022, to May 27, 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 99220: 
 
Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key 
components: A comprehensive history; A comprehensive examination; and 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 problem(s) requiring admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
CPT 99225: 
 
Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 
of these 3 key components: An expanded problem focused interval history; An expanded problem focused 
examination; Medical decision making of moderate 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 responding inadequately to 
therapy or has developed a minor complication. Typically, 25 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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the review has determined that 
regarding CPT 99220, the records supported a comprehensive history, and a comprehensive examination but 
not medical decision making of high complexity. For CPT 99225, the records did not support an expanded 
problem focused history and expanded problem focused examination. 
 
 
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 observation care (procedure codes 99220 and 99225) rendered from May 26, 2022, to May 27, 
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 15, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the denial. 
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 15, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Belbuca. 
 
You asked the Plan to pre-approve Belbuca. You say that the enrollee has tried and failed other pain 
medications. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B 
benefit. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Belbuca.  
 
Benefits for Belbuca may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (K0899). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that your current device is affecting the 
mobility on your right side. The Plan denied your request. The Plan says that the specific brand name scooter is 
not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a POV or PWC which has not been reviewed by 
the PDAC contractor or which has been reviewed by the PDAC and found not to meet the definition of a 
specific POV/PWC will be denied as not reasonable and necessary and should be coded as K0899. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power operated vehicle have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power operated vehicle (K0899).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020), single vision lens (V2100), and 
additional vision items or services (V2799) provided on November 26, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the frames, single vision lens, and additional vision items or services. You say 
that the treating provider does not carry glasses at their office, so you went elsewhere because they have a large 
selection of frames. You also say that you are on a fixed income, and would appreciate this appeal being 
honored. The Plan denied your request. The Plan says a prior authorization was not on file to obtain medical 
eyewear from out-of-network provider. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the frames (V2020), single vision lens (V2100), 
and additional vision items or services (V2799) provided on November 26, 2022, by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polymerase chain reaction (PCR) respiratory panel 
(87481, 87491, 87529, 87556, 87591, 87640, 87661, 87798) provided on August 5, 2022. 
 
You asked the Plan to pay for the PCR respiratory panel. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing was not billed with a single panel code as required. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PCR respiratory panel have not been met. Therefore, we decided that the Plan does not have to pay for the polymerase chain reaction (PCR) respiratory panel (87481, 87491, 87529, 87556, 87591, 87640, 
87661, 87798) provided on August 5, 2022.