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

 
We decided that the Plan does not have to pre-approve a custom fabricated socket insert for congenital or 
atypical traumatic amputee (L5681). 
 
You asked the Plan to pre-approve a custom fabricated socket insert for congenital or atypical traumatic 
amputee (L5681). The Plan denied your request. The Plan says the request for L5681 is not part of a 
replacement prosthesis and does meet Medicare criteria as reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that codes L5681 and L5683 are for use only with the 
initial issue of a custom fabricated socket insert. Additional inserts (either custom fabricated or prefabricated) 
provided at the time of initial issue or replacement socket inserts are coded L5673 and L5679, whichever is 
applicable. 
 
We looked at the file and Medicare rules. Specifically, the record shows that the enrollee has already been 
approved for coverage for a custom fabricated socket insert (L5673). Based on this information, we decided 
that Medicare rules for coverage of a custom fabricated socket insert for congenital or atypical traumatic 
amputee (L5681) have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
custom fabricated socket insert for congenital or atypical traumatic amputee (L5681).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 2, 2022, billed with 
multiple codes including 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 2, 2022, billed with multiple codes including 81351.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - two surfaces, posterior (D2392) 
provided on November 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not feel and did not know, with the 
$2,000 limit amount not reached, this claim should not be declined. 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. This benefit includes the 
requested resin-based composite - two surfaces, posterior (D2392) but is limited to two procedure codes per 
calendar year. 
 
We looked at the file, the Plan's rules, and Medicare's rules. You previously received covered resin-based 
composite - two surfaces, anterior (D2331) on July 7, 2022, and on November 10, 2022. You also received 
resin-based composite - two surfaces, posterior (D2392) on November 10, 2022. Although these are two 
different services, they fall within the same category in your Evidence of Coverage and are subject to the same 
frequency limitations. Therefore, these benefits were exhausted as of November 10, 2022. Therefore, we 
decided that the Plan does not have to pay for resin-based composite - two surfaces, posterior (D2392) 
provided on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 2D photographic image (D0350) and the removable 
appliance therapy (D8210) provided on September 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told you would be reimbursed since 
the dental procedures were for your health. The Plan denied your request. The Plan says the denial of payment 
for these services is correct, because the 2D photographic image and the removable appliance therapy 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 a 2D 
photographic image (D0350) and the removable appliance therapy (D8210) provided on September 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two additional units of procedure codes 70486 and 72125 
provided on September 11, 2022. 
 
You asked the Plan to pay for the additional units. 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 Medically Unlikely Edits (MUE) for CPT 70486 and CPT 72125 are 1. The MAI value for 
these codes is 3. 3 total units were billed for each of these codes. The imaging reports submitted were a 
duplicate. There is no evidence that more than one service was provided. Only one unit is supported. One unit 
of each of these codes were paid on a separate claim; therefore, the other two units on this claim cannot be 
paid. Based on this information, we decided that Medicare rules for coverage of the additional units have not 
been met. Therefore, we decided that the Plan does not have to pay for two additional units of procedure codes 
70486 and 72125 provided on September 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 20, 2022, billed 
with codes 81314, 81345 and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 20, 2022, billed with codes 81314, 81345 and 81272.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service April 22, 
2022. 
 
You asked the Plan to pay for procedure code 99223. You say that this service is supported as billed. The Plan 
denied your request. The Plan says the records provided do not support the level of service reported. 
 
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 99223 is initial hospital 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 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 procedure code 99223. Our reviewer says that code 99223 is 
not supported based on the medical records provided. Our reviewer found that medical decision making of high 
complexity is not supported for the date in question. Medical decision making of high complexity requires an 
extensive number of diagnoses or management options, an extensive amount and complexity of data reviewed 
and a high risk of complications. Three medical problems are reported in this case with review of laboratory 
testing and a computed tomography scan. The records don't support an extensive number of diagnoses or 
management options, or an extensive amount and complexity of data reviewed. With diagnoses of possible 
right hemiparesis, hypotension which was improving, and stable atrial fibrillation, the records do not support 
there was a high risk of complications. Because all three key components must be met in order to report code 
99223, this code is not supported in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 billed for date of service April 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Otto Bock C-leg 4 (L5828, L5845, L5848, and 
L5856) and Taleo Side Flex foot (L5981, L5986). 
 
You asked the Plan to pre-approve Otto Bock C-leg 4 and Taleo Side Flex foot. You say that with the enrollee's 
recent weight loss the current prosthesis is no longer fitting. You say that this proposes a risk of falling or 
injury. You say that a new foot and knee is needed because the enrollee's activities have increased along with 
her K level and daily activities. The Plan denied your request. The Plan says the documentation does not 
support the need for microprocessor knee instead of mechanical knee based on documented activity needs. The 
Plan also says that the enrollee's activity needs can be met with mechanical knee. 
 
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 the Ottobock C-leg 4 and Taleo Side Flex foot have not been classified by Medicare for coverage 
at this time. Other equipment may meet the enrollee's needs. Based on this information, we decided that 
Medicare rules for coverage of Otto Bock C-leg 4 and Taleo Side Flex foot have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an Otto Bock C-leg 4 (L5828, L5845, L5848, and L5856) 
and Taleo Side Flex foot (L5981, L5986).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required 
(D2950), surgical placement of implant body; endosteal implant (D6010), custom fabricated abutment - 
includes placement (D6057), abutment supported porcelain/ceramic crown (D6058), and bone graft at time of 
implant placement (D6104). 
 
You asked the Plan to pre-approve dental services. You say that you would like your insurance to make an 
exception and honor the dental implant claim toward the $4,000 annual maximum. The Plan denied your 
request. The Plan says this service is not covered under your Plan. 
 
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. Core buildup, including any 
pins when required (D2950), surgical placement of implant body; endosteal implant (D6010), custom 
fabricated abutment - includes placement (D6057), abutment supported porcelain/ceramic crown (D6058), and 
bone graft at time of implant placement (D6104) are not covered under the Plan's dental benefits. 
 
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 core 
buildup, including any pins when required (D2950), surgical placement of implant body; endosteal implant 
(D6010), custom fabricated abutment - includes placement (D6057), abutment supported porcelain/ceramic 
crown (D6058), and bone graft at time of implant placement (D6104).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 30, 2022, billed with 
codes 81201, 81292, 81295, 81298, 81307, 81314, 81317, 81321, 81334 and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 30, 2022, billed with codes 81201, 81292, 81295, 81298, 81307, 81314, 81317, 81321, 81334 and 
81351.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core build-up (D2950). 
 
You asked the Plan to pre-approve a core build-up (D2950). You say that you need this dental work. The Plan 
denied your request. The Plan says the requested services have been correctly denied. 
 
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 a 
core build-up (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient evaluation and management (EM) services 
provided on March 14, 2022, billed with code 99222. 
 
You asked the Plan to pay for the inpatient EM services as billed. You say that it is felt that code 99222 is 
supported. The Plan denied your request. The Plan says the code billed 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 99222 is Initial hospital 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 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 problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 
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 EM services as billed. Our 
reviewer says that the billed code is not supported for the services rendered. Our reviewer found the enrollee is 
a 75-year-old female who presented to the hospital with chest pain and was diagnosed with hypo-
osmolality/hyponatremia (sodium 121). She has polycystic kidney disease, hypertension, and has a history of 
chest pain and palpitations. She has refused cardiac/ischemia workup as outpatient, and an echocardiogram 
years prior was unremarkable. A limited examination was unremarkable in the documentation. Cardiac 
catheterization was negative. It was revealed that she drinks excessive amounts of water. Based on the provided 
documentation, the code, 99222, was not appropriate as there was not a comprehensive history and 
examination, and the enrollee did not require medical decision making of moderate complexity. 
 
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 inpatient EM services as billed have not been met. Therefore, we decided 
that the Plan does not have to pay for the inpatient evaluation and management (EM) services provided on 
March 14, 2022, billed with code 99222.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 92611, 74240, and 74230 provided on 
November 3, 2022. 
 
You asked the Plan to pay for procedure codes 92611, 74202, and 74230. You say that these services were 
provided at the request of the primary care physician at the facility. You say that the provider is contracted with 
the facility. You also say that the enrollee had a documented limitation for transporting. The Plan denied your 
request. The Plan says the services in this case are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures and examinations which are not 
covered under the portable x-ray provision includes procedures involving the use of contrast media. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient services have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 92611, 74240, and 74230 provided on November 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional fractions of intensity-modulated radiation 
therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that this is medically reasonable and necessary. The Plan 
denied your request. The Plan says 35 fractions is the standard of care. 
 
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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in general, there is no evidence basis to use more than 35 fractions of IMRT at greater than 1.8 
grays (Gy) per fraction. The request does not provide any rationale for using 1.8Gy fractions, the result of 
which is simply to prolong treatment without any known or accepted benefit.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve 4 additional fractions of intensity-modulated radiation therapy (IMRT).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vivex cygnus amniotic tissue allograft (20930 x 3). 
 
You asked the Plan to pre-approve the allograft. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the Vivex cygnus amniotic tissue 
allograft in the setting of a spine fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 the allograft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this 
requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies are needed 
to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested Vivex cygnus amniotic tissue allograft in the setting of spinal 
fusion, in this case, is not medically reasonable or 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 the allograft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vivex cygnus amniotic tissue allograft (20930 x 3).