Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service September 
10, 2022, to October 7, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that care was provided to avoid complications. 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. 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 pay for procedure 
code S9328 billed for date of service September 10, 2022, to October 7, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for SelectMDx testing for prostate cancer (81479) provided on January 20, 
2022. 
 
You asked the Plan to pay for SelectMDx testing. You say that this test was medically reasonable and 
necessary. The Plan denied your request. The Plan says that this test was not medically necessary and is 
considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for SelectMDx testing. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the National Comprehensive Cancer Network (NCCN) Guideline Version 2022 for Prostate 
Early Detection includes the following statement regarding this test, "overall, the panel believes that 
SelectMDx score is potentially informative in patients who have never undergone biopsy, and it can therefore 
be considered in such individuals." The records do not show that the enrollee has had a prostate biopsy, and 
therefore is an appropriate candidate for SelectMDx testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SelectMDx testing have been met. Therefore, we decided that the Plan has to 
pay for SelectMDx testing for prostate cancer (81479) provided on January 20, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 27808 and 99053 billed for date of service 
April 12, 2022.  

You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed codes remain 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 27808 is closed treatment of bimalleolar ankle fracture 
(e.g., lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli); without 
manipulation. We find that CPT code 27808 is not supported in the medical record. Specifically, the records do 
not show that code 27808 was provided on the date of service at issue.  
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 27808 and 99053 billed for date of service April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic brachytherapy. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says based on the additional information available, the request does not meet the Medicare or 
health plan coverage criteria. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that electronic brachytherapy is currently subject only to medical device review by the Food and Drug 
Administration (FDA), which considers safety and effectiveness of the device based on a standard that does not 
assess efficacy, outcomes, or potential clinical applications. For this case, there are no compelling reasons 
offered for why this therapy would be needed over more standard approaches of radiation delivery. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve electronic brachytherapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the attendant control (E2331) and redesigned back 
(E1028 x 2). 
 
You asked the Plan to pre-approve the attendant control and redesigned backs. You say that the requested items 
are medically necessary. The Plan denied your request. The Plan says that an attendant control is not covered if 
a user-operated control is requested. The Plan also says that the resigned backs are not covered when related to 
back cushion mounting hardware. 
 
The Plan must follow Medicare rules. Medicare rules say that if an attendant control (E2331) is provided in 
addition to a beneficiary-operated drive control system, it will be denied as non-covered. Medicare rules also 
says that code E1028 must not be used for mounting hardware related to a wheelchair seat cushion or back 
cushion code. 
 
We looked at the file and Medicare rules. An attendant control is not covered in addition to the beneficiary-
operated drive control. Code E1028 for redesigned backs is not covered when relating to back cushion 
mounting hardware. Therefore, we decided that the Plan does not have to pre-approve the attendant control 
(E2331) and redesigned back (E1028 x 2).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 20610 billed for date of service July 26, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request.  
 
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 CPT Code Manual definition of code 20610 is arthrocentesis, aspiration and/or injection, major 
joint or bursa (e.g., shoulder, hip, knee, subacromial bursa), without ultrasound guidance.  
 
We find that CPT code 20610 is supported in the medical record. In this case, the MUE for CPT code 20610 is 
2. The MAI value for this code is 3. You billed 3 units of this code, exceeding the MUE. The medical records 
show that the enrollee received a shoulder injection, a right knee injection, and a left knee injection. The 
documentation provided included evidence showing 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 of the billed services have been met. Therefore, we decided that the Plan has to pay for procedure code 20610 billed for date of service July 26, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after 
March 3, 2023. 
 
You asked the Plan to pre-approve SNF care after March 3, 2023. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care after March 3, 2023. Our 
reviewer says that the requested SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found you do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility 
(SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care after March 3, 2023, have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after March 3, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service November 
28, 2022. 
 You asked the Plan to pay for procedure code 76705. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into 
payment for code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service November 28, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76706 billed for date of service September 9, 
2022. 
 
You asked the Plan to pay for procedure code 76706. You say that this service is supported as billed. The Plan 
denied your request. The Plan says payment for code 76706 is bundled into payment for code 93979. 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 76706 
is a column II code to column I code 93979. 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 76706 billed for date of service September 9, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical each additional radiographic image 
(D0230), and prophylaxis - adult (D1110) provided on October 24, 2022. 
 
You asked the Plan to pay for codes D0230 and D1110. You say that you were not informed that your dentist's 
contract had expired with the Plan. The Plan denied your request. The Plan says your benefit for the requested 
items or services 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 intraoral - periapical each additional radiographic image (D0230) was exhausted on 
date of service October 24, 2022 (which shares frequency with code D0220 on the reprocessed appealed 
claim). The prophylaxis - adult (D1110) was exhausted on dates of service March 21, 2022 and June 28, 2022. 
Therefore, we decided that the Plan does not have to pay for an intraoral - periapical each additional 
radiographic image (D0230), and prophylaxis - adult (D1110) provided on October 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on August 12, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on August 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93318 billed for date of service May 24, 
2022. 
 
You asked the Plan to pay for procedure code 93318. The Plan denied your request. The Plan says payment for 
code 93318 is bundled into payment for code 00567.  
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 93318 
is a column II code to column I code 00567. 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 93318 billed for date of service May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a false tooth for bridge (D6240) for tooth #7 and tooth 
#9, and a prefabricated abutment (D6056) and abutment supported cast metal crown (D6062) for tooth #10, #5, 
#6 and #8. 
 
You asked the Plan to pre-approve the dental services. You say that you want a bridge to replace your missing 
teeth. The Plan denied your request. The Plan says a false tooth for bridge (D6240) for tooth #7 and tooth #9 
does not meet the criteria for coverage. The Plan also says that prefabricated abutments (D6056) and abutment 
support crowns (D6062) are not covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 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 dental services. Our reviewer says 
the requested services are not within the coverage criteria. Our physician reviewer found according to the Plan, 
fixed bridges are usually considered beyond the scope of the program. However, an allowance for fixed bridges 
is available and limited to anterior maxillary three unit bridges (one missing maxillary tooth), and anterior 
mandibular bridges up to four units (two missing adjacent mandibular teeth). Bridges will only be covered if no 
other teeth are missing in the same arch other than third molars. In this instance, there are at least two teeth 
being replaced by way of implants, which are not a covered service. Specifically, implant and all related 
services are excluded, which would include implant supported bridges and pontics. Given the Plan limitations, 
the requested services are not within the coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a false tooth for bridge (D6240) for tooth #7 and tooth #9, and a prefabricated 
abutment (D6056) and abutment supported cast metal crown (D6062) for tooth #10, #5, #6 and #8.
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 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service June 1, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the records do 
not support the code 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 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total 
time is spent on the date of the encounter. 
 
We find that CPT code 99214 is not supported in the medical record. Specifically, the records do not indicate 
the total time spent on the date of the encounter. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99214 billed for date of service June 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for elbow orthosis (eo), with adjustable position locking joint(s), 
prefabricated, off-the-shelf provided on July 21, 2022. 
 
 
You asked the Plan to pay for the item. You say that medical records were submitted for review. The Plan 
denied your request. The Plan says the documentation submitted did not sufficiently support the billed supply 
code.  
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 item. 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 documentation available for review does not support the need for a prefabricated 
elbow orthosis.  There is no indication of injury or illness associated with the elbow and no physical exam 
findings that would require an elbow orthosis. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pay for elbow orthosis (eo), with adjustable position locking joint(s), prefabricated, off-the-shelf provided on 
July 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue (D7286). 
 
You asked the Plan to pre-approve an incisional biopsy of oral tissue. You say that the service is necessary. The 
Plan denied your request. The Plan says the service at issue is not a covered benefit. 
 
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 an 
incisional biopsy of oral tissue (D7286).