Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown porcelain/ceramic (D2740) and the nitrous oxide
(D9230) provided on December 8, 2021.
You asked the Plan to pay for the dental services. You say that you paid for these services and have not
received reimbursement. The Plan denied your request. The Plan says that you have already received the
maximum amount of coverage allowed for this type of service.
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. The Plan covers up to a $1,000
allowance for dental services every year.
The file shows that the Plan has already approved the maximum yearly benefit of $1,000 for dental services on
September 21, 2021.
There is no provision in the contract which would require the Plan to approve more than this amount.
Therefore, we decided that the Plan does not have to pay for the crown porcelain/ceramic (D2740) and the
nitrous oxide (D9230) provided on December 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76937 billed for date of service September 
17, 2021. 
 
You asked the Plan to pay for procedure code 76937. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76937 is bundled into payment for 
code 93970. 
 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 76937 
is a column II code to column I code 93970. 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 76937 billed for date of service September 17, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic services (A0432) provided on July 5, 2022. 
 
You asked the Plan to pay for the paramedic services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code A0432 is not supported in the medical record. Specifically, the base ambulance code 
was not billed with a required mileage code. Based on this information, we decided that Medicare rules for 
coverage of the paramedic services have not been met. Therefore, we decided that the Plan does not have to 
pay for paramedic services (A0432) provided on July 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection procedure for contrast knee arthrography or 
contrast enhanced CT/MRI knee arthrography (27369) provided June 21, 2022. 
 
You asked the Plan to pay for the injection procedure. You say that this claim is being denied in error. These 
are payable codes. See date of service for June 21, 2022, that was billed the exact same way and paid. The Plan 
denied your request. The Plan says services do not meet coverage requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the injection procedure have been met. 
the records received were for a different date of service than that on the claim form. Records show that the Plan 
made multiple attempts to obtain the additional records from the provider without success. Therefore, we 
decided that the Plan does not have to pay for the injection procedure for contrast knee arthrography or contrast 
enhanced CT/MRI knee arthrography (27369) provided June 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom CGM. 
 
You asked the Plan to pre-approve a Dexcom CGM. You say that the requested CGM is medically necessary. 
The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the 
blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a 
Dexcom CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom 
CGM.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive 
pulmonary disease (COPD) with repeated hospitalizations. Arterial blood gases (ABGs) in hospital have been 
consistent with acute on chronic hypercarbic respiratory failure. The enrollee has been discharged on standard 
bilevel positive airway pressure (BiPAP) in the past, but there is no documentation of usage. This enrollee may 
benefit from BiPAP with average volume-assured pressure support (AVAPS) during sleep as an outpatient. There is no evidence this has been tried. Medicare does not cover a home ventilator when used as BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for 
date of service February 26, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360 and 88381. You say that these services 
were medically necessary. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360 and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360 and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for date of service February 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime for oxygen 
equipment is 5 years.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a portable oxygen concentrator have not been met. Specifically, you received a portable oxygen 
concentrator on April 7, 2022. You do not qualify for a replacement until you have had the equipment for 5 
years. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator 
(E1392).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for code 77065 billed for June 29, 2022. 
 
You asked the Plan to pay for code 77065. The Plan denied your request. The Plan says that the MUE value has 
been exceeded. 
 
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. The Plan argues that the provider billed two units of code 77065, exceeding the 
MUE value of 1. However, the documentation submitted by the Plan shows that only one unit of code 77065 
was billed for the date of service in question. Without supporting documentation, the Plan's denial cannot be 
substantiated. Therefore, we decided that the Plan has to pay for code 77065 billed for June 29, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with single power 
option. 
 
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 a Group 3 PWC with single power option is 
covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a qualifying diagnosis 
of a stroke with hemiplegia. The documentation indicates she has a mobility deficit that impairs the ability to 
complete mobility-related activities of daily living (MRADLs) in the home and that she is unable to use a 
walker, manual wheelchair, or cane due to weakness. The documentation does not reveal that he uses 
intermittent catheterization. He is not at high risk for pressure ulcers. The physician documentation does not 
indicate objective evidence of spasticity on a bilateral lower extremity physical exam that needs a power 
seating system for management therefore the request for power tilt exceeds his medical needs. The  tilt option 
exceeds the enrollee's medical needs; therefore, the Group 3 power wheelchair with single power option  and 
Power Tilt recline (E1002) is not 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 Group 3 power wheelchair (PWC) with single power option.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
15, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on the date 
in question. 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 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 15, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve MRI, spinal canal and contents, lumbar; without contrast material 
(CPT code 72148). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is necessary. The Plan denied your request. 
The Plan says that the MRI is not medically necessary. 
 
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 MRI. Our physician reviewer found 
the additional clinical documentation supports that the coverage criteria for an MRI of the lumbar spine have 
been met in this case. The enrollee has severe pain, an abnormal reflex, a positive straight leg raise, and has 
failed six (6) weeks of conservative treatment. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
MRI, spinal canal and contents, lumbar; without contrast material (CPT code 72148).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 3, 2022, to 
May 2, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 3, 2022, to May 2, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291) provided on June 30, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that when the critical care service is unrelated to the 
procedure, append the modifier -FT.  
 
We looked at the file and Medicare rules. In this case, modifier -FT was not appended to code 99291 to 
indicate that the critical care services were unrelated to the procedure provided on the next day. As such, 
payment for code 99291 is included in the global surgery payment for code 44310 provided on July 1, 2022. 
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 the critical care services (99291) provided on June 
30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the orthopedic mens oxford shoes (CPT code L3219). 
 
You asked the Plan to pre-approve the shoes. You say that your provider wanted you to have a specialized shoe 
to help with long-term success and less painful action. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Furthermore, code L3219 is not covered. The rules say that orthopedic footwear billed using codes 
L3219 will be denied as noncovered. Therefore, we decided that the Plan does not have to pre-approve the 
orthopedic mens oxford shoes (CPT code L3219).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360 and 88381 billed for 
date of service February 1, 2022. 
 
You asked the Plan to pay for procedure codes 88341, 88342, 88360 and 88381. You say that the services at 
issue have been billed correctly. The Plan denied your request. The Plan says rules for payment have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that payment is not made under the physician fee 
schedule for TC services furnished in institutional settings where the TC service is bundled into the facility 
payment, e.g., hospital inpatient and outpatient settings. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 88341, 88342, 88360 and 88381 have not been met. Specifically, the records 
suggest that these services were rendered in an outpatient facility. Procedure codes 88341, 88342, 88360 and 
88381 have a professional/technical component indicator of 1. This means that these codes have a professional 
and technical component. These codes have not been billed with the appropriate modifier to indicate that they 
are for the professional component. Payment for the technical component of these codes is included in the 
payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the 
Plan does not have to pay for procedure codes 88341, 88342, 88360 and 88381 billed for date of service 
February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service May 15, 
2022. 
 
You asked the Plan to pay for procedure code 93042. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 93042 is bundled into payment for code 93010.  
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 93042 
is a column II code to column I code 93010. 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 93042 billed for date of service May 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 24, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on February 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 29, 2022.

You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 29, 2022.