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

 
We decided that the Plan does not have to pre-approve a power seat elevation feature for a power wheelchair. 
 
You asked the Plan to pre-approve power seat elevation feature. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says a power seat elevation feature is not covered 
by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation feature have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power seat elevation feature for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #29 (D2740). 
 
You asked the Plan to pre-approve a crown. You say that the requested services are medically necessary. 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 date of service July 22, 2019. Therefore, 
we decided that the Plan does not have to pre-approve a crown on tooth #29 (D2740).
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 23, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. 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 23, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
November 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that the technician tried to get the x-rays from the 
other provider but it was taking too long so they took another one. 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 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 your benefit for the requested item or service was exhausted on date of service November 14, 2022 (this 
claim was submitted to the Plan 1st for processing). Therefore, we decided that the Plan does not have to pay 
for a panoramic radiographic image (D0330) provided on November 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77003 billed for date of service August 25, 
2022. 
 
You asked the Plan to pay for procedure code 77003. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 77003 is bundled into 
payment for code 64490. 
 
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 77003 
is a column II code to column I code 64490. 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 77003 billed for date of service August 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on 
February 1, 2021. 
 
You asked the Plan to pay for the hospital discharge day management. You say that you do not believe you are 
legally responsible for this claim. The Plan denied your request. The Plan says the enrollee was in hospice 
during this date of service. The Plan also says while the enrollee is in the hospice program, their hospice 
provider will bill Original Medicare for the services that Original Medicare pays for. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on 
February 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (Q9967, S0020 and J2001) provided 
on May 31, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the anesthesia services have not been met. Medicare guidance says 
CPT code S0020 has a status code of I. You can find this guidance in the Year National Physician Fee 
Schedule Relative Value File Month Release. Medicare guidance says status code "I = Not valid for Medicare 
purposes. Medicare uses another code for reporting of, and payment for, these services. In the event an 
anesthesia administration service is provided during a different operative session on the same day as a previous 
operative session, one additional anesthesia administration will be reimbursed if billed with modifier 59, 76, 
77, 78, 79 or XE. Therefore, we decided that the Plan does not have to pay for the anesthesia services (Q9967, 
S0020 and J2001) provided on May 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on June 6, 2022, 
billed with codes 36415, G0402, and G0463. 
 
You asked the Plan to pay for the hospital services as billed. You say that this should be paid as the services 
were medically necessary. The Plan denied your request. The Plan says this cannot be paid until a corrected 
claim is submitted to cure the errors. 
 
The Plan must follow Medicare rules. Medicare rules say that OPPS claims with multiple medical visits on the 
same date in the same revenue center should report condition code G0. 
 
We looked at the file and Medicare rules. Two medical visits were billed on this claim, G0402 and G0463. 
Condition code G0 is not reported as required. Based on this information, we decided that Medicare rules for 
coverage of the hospital services as billed have not been met. Therefore, we decided that the Plan does not have 
to pay for the outpatient hospital services provided on June 6, 2022, billed with codes 36415, G0402, and 
G0463.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the REVOFit socket system to be described by code 
L5999. 
 
You asked the Plan to pre-approve the REVOFit socket system with L5999. You say that the REVOFit system 
is needed due to the fluctuating edema in the residual limb. This requires adjustable tension in the panels to 
prevent injury. The Plan denied your request. The Plan says the REVOFit system is a socket feature, and the 
rules indicate that L5999 is incorrect coding when used to describe any feature of a socket. 
 
The Plan must follow Medicare rules. Medicare rules say that code L5999 must not be used to bill for any 
features or functions included in the socket or addition codes.  
 
We looked at the file and Medicare rules. Although the feature itself may be appropriate, use of the requested 
code to describe this system is not correct. Based on this information, we decided that Medicare rules for 
coverage of the REVOFit socket system with L5999 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the REVOFit socket system to be described by code L5999.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 provided on August 13, 2022, and 
August 14, 2022. 
 
You asked the Plan to pay for procedure code 93042. 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 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 93042 is Rhythm ECG, 1-3 leads; interpretation and 
report only. 
 
We find that CPT code 93042 is not supported in the medical record. Specifically, the medical records do not 
document that an ECG with 1-3 leads was interpreted and reported on the dates of service at issue. Based on this information, we decided that Medicare rules for coverage of procedure code 93042 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 93042 provided on August 13, 
2022, and August 14, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 80307. We decided that the Plan does not have to pay 
for procedure code 83789.  
 
You asked the Plan to pay for drug testing services (80307 and 83789) provided on September 16, 2022. You 
say that these services were necessary and are supported as billed. The Plan says that code 83789 is not 
separately payable from the drug testing provided, and only one presumptive drug testing service from the 
80305-80307 code set may be paid per date of service. 
 
We decided that the Plan has to pay for procedure code 80307.  
 
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 has provided no evidence to show that any other 
presumptive drug testing from the 80305-80307 code range has been reported/billed for this enrollee on the 
same date of service. The Plans denial of this service is not substantiated in this case. Therefore, we decided 
that the Plan has to pay for procedure code 80307.  
 
We also decided that the Plan does not have to pay for procedure code 83789. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for procedure code 83789. 
 
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 further pay for procedure code 72148 billed for date of service June 
22, 2022. 
 
You asked the Plan to further pay for procedure code 72148. You say that the codes were billed with 
appropriate modifiers. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 72148 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide documentation to show that the excess units were actually 
provided, were correctly coded, and were medically necessary. 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 further 
pay for procedure code 72148 billed for date of service June 22, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ground mileage (A0425) provided on April 28, 2022. 
 You asked the Plan to pay for the ground mileage. You say that the ambulance transport was medically 
necessary. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the 
enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ground mileage (A0425) provided on April 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
total right reverse shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your 
request. The Plan says there is no documentation provided to support the expectation the enrollee will require a 
greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   

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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is approved for a total right reverse shoulder arthroplasty. The 
record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 
or more midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vitoss allograft. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is limited published, large-scale, 
long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the 
enrollee's pathology. Further studies are needed to demonstrate this request has beneficial outcomes compared 
with conventional/standard treatment. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. The allograft is therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vitoss allograft.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 84480 billed for date of service July 29, 
2022. 
 
You asked the Plan to pay for procedure code 84480. You say that these services were medically necessary and 
appropriate. The Plan denied your request. The Plan says payment for code 84480 is bundled into payment for 
code 84481. 
 
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 84480 
is a column II code to column I code 84481 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 84480 billed for date of service July 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown lengthening on tooth #6, 10, and 11 (D4249). 
 
You asked the Plan to pre-approve crown lengthening. You say that the requested dental work is medically 
necessary. The Plan denied your request. The Plan says that crown lengthening (D4249) is not covered by 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 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 pre-approve 
crown lengthening on tooth #6, 10, and 11 (D4249).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) non-segmented 
pneumatic compressor (E0650) and pump for water circulating pad (E0236) provided October 3, 2022, to 
October 27, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you are appealing the denial of 
some of your medical equipment that you needed after your knee replacement surgery. The compression device 
was needed to prevent blood clots which you have a history of. The Plan denied your request. The Plan says 
pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or 
following surgery. Medicare does not cover fluid circulating cold pads with pumps. 
 The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) non-segmented pneumatic compressor (E0650) and pump for 
water circulating pad (E0236) provided October 3, 2022, to October 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150, 87481, 87500, 87640, 87641, 87653, 
87798) provided on June 6, 2022. 
 You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (87150, 87481, 87500, 87640, 87641, 87653, 87798) provided on 
June 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing billed with code G0481 for April 22, 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 procedure code G0481 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 G0481 is definitive drug testing, 8-14 drug classes. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, the file shows that testing of 8-14 drug classes was not ordered. 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 drug testing 
billed with code G0481 for April 22, 2022.