Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed for date of service June 29, 
2022 to June 30, 2022. 
 
You asked the Plan to pay for procedure code S9500. You say that you have provided records to support 
payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9500 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9500 billed for date of service June 29, 2022 to June 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service October 25, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that one of the units of this code 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 cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. In addition, the rules say that if the MUE is a date of service MUE (which this one 
is), all units of service for the same date of service on all claim lines are summed and if they exceed the MUE, 
all units of service for that code are denied. Based on this information, we decided that Medicare rules for 
coverage of procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 86077 billed for date of service October 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neck/spine x-ray (CPT 72040), an x-ray of jaw  
(CPT 70100), a swallowing function x-ray (CPT 74230), diagnostic radiology procedures of the head and neck 
(CPT 70310), an upper gastrointestinal tract x-ray (CPT 74240), and speech-language pathologist's 
participation in the MBS or videofluoroscopy (code 92611) provided on October 21, 2022. 
 
You asked the Plan to pay for a neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100), a swallowing 
function x-ray (CPT 74230), diagnostic radiology procedures of the head and neck (CPT 70310), an upper 
gastrointestinal tract x-ray (CPT 74240), and speech-language pathologist's participation in the MBS or 
videofluoroscopy (code 92611). 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. Based on this information, we decided that Medicare rules for 
coverage of a neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100), a swallowing function x-ray (CPT 
74230), diagnostic radiology procedures of the head and neck (CPT 70310), an upper gastrointestinal tract x-
ray (CPT 74240), and speech-language pathologist's participation in the MBS or videofluoroscopy (code 
92611) have not been met. Therefore, we decided that the Plan does not have to pay for a neck/spine x-ray 
(CPT 72040), an x-ray of jaw (CPT 70100), a swallowing function x-ray (CPT 74230), diagnostic radiology 
procedures of the head and neck (CPT 70310), an upper gastrointestinal tract x-ray (CPT 74240), and speech-
language pathologist's participation in the MBS or videofluoroscopy (code 92611) provided on 
October 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37221 billed for date of service November 
30, 2021. 
 You asked the Plan to pay for procedure code 37221. You say that this procedure was performed once on each 
side. 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 37221 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 37221 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 37221 billed for date of 
service November 30, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided October 20, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that please see the attached proof that this claim 
was originally submitted to Medicaid within the timely filing deadline before you discovered that this enrollee 
had the Plan as the primary policy and re-billed the claim for processing. The Plan denied your request. The 
Plan says the claim was filed after the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the outpatient services was not filed until December 15, 2022. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the outpatient hospital services provided October 20, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on August 8, 2021. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says 12 
months from the date of service is the timely filing limit for claim submission. Submission beyond this limit 
without good cause will be denied. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency department visit was not filed until November 23, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on 
August 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on June 4, 2021. 
 
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 there is no valid order. 
 
The Plan must follow Medicare rules. The rules say that HHAs may not submit a claim until after all services 
are provided for the period and the physician has signed the plan of care and any subsequent verbal order. 
 
We looked at the file and Medicare rules. The file shows that there is no valid order for the date of service at 
issue. 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 home health services rendered on June 4, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on March 20, 2022, 
through March 25, 2022, and billed with diagnosis code A40.3. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
documentation submitted does not support primary diagnosis of A41.9. The Plan denied your request. The Plan 
says the documentation submitted does not support primary diagnosis of A41.9. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with primary diagnosis code A40.3-sepsis due to 
Streptococcus pneumoniae. 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 pay for the inpatient 
hospital services at the DRG originally billed. Our reviewer says that the documentation does not support the 
primary diagnosis of A40.3-sepsis due to Streptococcus pneumoniae. Our physician reviewer found the 
member's blood cultures came back positive for gram-positive cocci with a Bio fire showing Streptococcus 
pneumoniae. The member was called to return to the hospital on March 20, 2022, for treatment and 
observation. The member's blood pressure was at 134/66, hear rate 88, respiratory rate 17, and oxygen 
saturation at 95% on room air. The member had to have repeat labs on the same day which showed the 
member's white blood count 10.2, platelets 139, creatinine 1.19, and total bilirubin 0.7. Per history and physical 
provider exam, no apparent distress and oriented to person, place, and time. There was no clinical or laboratory 
evidence of sepsis. Therefore, diagnosis code A40.3 is not the appropriate primary diagnosis code.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 20, 2022, through March 25, 2022, and billed with diagnosis 
code A40.3.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for physician's services provided on 
November 21, 2022. 
 
You asked the Plan to reimburse you for the physician's services. The Plan denied your request. The Plan says 
the provider is not under contract with the health Plan and is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
physician's services provided on November 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus HRD test aid (81479) provided on July 7, 2022. 
 
You asked the Plan to pay for the Tempus HRD test aid. You say that this test was medically necessary. The 
Plan denied your request. The Plan says this test is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus HRD test aid is not FDA approved. 
Based on this information, we decided that Medicare rules for coverage of the Tempus HRD test aid have not 
been met. Therefore, we decided that the Plan does not have to pay for the Tempus HRD test aid (81479) 
provided on July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D4266 or D4265, D6100, D7953). 
 
You asked the Plan to pre-approve the dental services (D4266 or D4265, D6100, D7953). You say that you 
would like to request reconsideration of the denied authorization. The Plan denied your request. The Plan says 
the services requested are not covered 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 the 
dental services (D4266 or D4265, D6100, D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on November 
14, 2022. 
 
You asked the Plan to pay for the dental services. You say that this is a preventive measure and in the long run 
will save your teeth. The Plan denied your request. The Plan says this service is not a covered benefit under 
your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
periodontal maintenance (D4910) provided on November 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that these benefits have helped you tremendously, 
your health is still the same, and you would like your benefits to be reinstated. The Plan denied your request. 
The Plan says the criteria for eligibility have not been met. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service November 7, 
2022. 
 You asked the Plan to pay for procedure code 81345. You say that these services were medically necessary. 
The Plan denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 81345 
is a column II code to column I code 0089U. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 81345 billed for date of service November 7, 
2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve Accu-Chek guide test strips. 
 
You asked the Plan to pre-approve the Accu-Chek guide test strips. You say that this is a medical necessity. 
 The Plan denied your request. The Plan says that the records sent to us by your doctor do not show why the 
Accu-chek is better than the machines on the Plan's list of approved items. 
 
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 Plans 2023 Evidence of Coverage states prior authorization is 
not required for preferred manufacturer. The Plan has not substantiated their denial reason because it does not 
specify the enrollee is contractually required to use preferred-brand products. Therefore, we decided that the 
Plan has to pre-approve Accu-Chek guide test strips.  
 
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 pay for revision of bilateral reconstructed breasts with mastopexy, 
liposuction, and nipple reconstruction rendered on June 13, 2022. 
 
You asked the Plan to pay for the surgery. You say that this was medically necessary. The Plan denied your 
request. The Plan says there is no significant asymmetry or axillary fullness that would suggest a functional 
impairment. 
 
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 pay for the surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the record indicates that the enrollee has had breast reconstruction after prophylactic 
mastectomies and had subsequent reconstruction. The record provided does not establish that the performed 
procedures were to restore and improve function and correct any deformities or abnormal structures of the body 
that have been caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. The elements of the coverage criteria are not satisfied. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pay for revision of bilateral reconstructed breasts with mastopexy, liposuction, and nipple 
reconstruction rendered on June 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoperative identification (eg, mapping) of sentinel lymph 
node(s) rendered on 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 code 38900 is "Intraoperative identification (eg, mapping) of 
sentinel lymph node(s) includes injection of non-radioactive dye, when performed (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 not supported by the medical records. Our reviewer found that CPT code 38900 is not supported. 
The record states that technetium was injected, which is a radioactive substance. There is a more specific code 
for sentinel lymph note mapping with a radioactive substance.  
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 intraoperative identification (eg, mapping) of sentinel lymph node(s) rendered on May 27, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the folding walker provided on October 24, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 folding walker provided on October 24, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 billed for date of service January 6, 
2022. 
 
You asked the Plan to pay for procedure code 99204. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99204 is bundled into payment for code 99205. 
 
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 99204 is a column II code to column I code 99205 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 99204 billed for date of service January 6, 2022.