Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing (87798, 87641, 88305, 88312) provided to the 
enrollee on November 9, 2021. 
 
You asked the Plan to pay for the lab testing. You say that these services should be reconsidered for payment. 
The Plan denied your request. The Plan says that there are no authenticated records. 
 
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 lab testing (87798, 87641, 88305, 
88312) provided to the enrollee on November 9, 2021, have been met. The file did not include an order form 
nor the lab report with results of testing. Therefore, we decided that the Plan does not have to pay for the lab 
testing (87798, 87641, 88305, 88312) provided to the enrollee on November 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 12 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided January 
12, 2022 to February 10, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you disagree with this denial and 
believe these services were medically necessary. The Plan denied your request. The Plan says pneumatic 
compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following 
surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided January 12, 2022 to February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341 and 88342 billed for date of service 
April 4, 2022. 
 
You asked the Plan to pay for procedure codes 88341 and 88342. The Plan denied your request. The Plan says 
these services are not payable 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. In this case, we have confirmed that code 88342 
is a column II code to column I code 88189. 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. 
 
Additionally, we have confirmed that code procedure code 88341 is an add-on code and has not been billed 
with an appropriate primary procedure code. 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 codes 88341 and 88342 billed 
for date of service April 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7140) provided by a participating provider 
on April 1, 2022. 
 
You asked the Plan to pay for an extraction. You say that you believe you should not have to pay for this. The 
Plan denied your request. The Plan says the rendered dental service 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 pay for an 
extraction (D7140) provided by a participating provider on April 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne Heme (F1Heme) comprehensive testing 
(81455) billed for date of service January 18, 2022. 
 
You asked the Plan to pay for F1Heme testing. You say that this testing was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this code is non-covered as it is 
deemed generally not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that certain codes are automatically denied as not 
medically necessary as they are unlikely to impact therapeutic decision making in the clinical management of a 
patient.  
 
We looked at the file and Medicare rules. At the time of services, code 81455 was listed under the Group 3 
Paragraph of Article A56199. This means that this service is considered automatically denied as not medically 
necessary. Therefore, we decided that the Plan does not have to pay for FoundationOne Heme (F1Heme) 
comprehensive testing (81455) billed for date of service January 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lift chair received on March 14, 2022. 
 
You asked the Plan to pay for the chair. You say that you bought this at a furniture store because it was reduced 
to almost half-price. The Plan denied your request. The Plan says the provider is not certified for Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program.  
 
The furniture store is not eligible to bill Medicare. UnitedHealthcare did not pre-approve the chair. We found 
no exception that would require UnitedHealthcare to pay for the chair. Based on this information, we decided 
that Medicare rules for coverage of the chair have not been met. Therefore, we decided that the Plan does not 
have to pay for a lift chair received on March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an obturator prosthesis (D5932) provided on May 9, 2022. 
 
You asked the Plan to pay for an obturator. You say that a new obturator was medically necessary. The Plan 
denied your request. The Plan says an obturator prosthesis (D5932) is not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
obturator prosthesis (D5932) provided on May 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Fluoroscopic guidance for needle placement (77002-26-
XU-LT and 77002-26-76-RT) provided on December 3, 2021. 
 
You asked the Plan to pay for codes 77002-26-XU-LT and 77002-26-76-RT. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered 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 codes 77002-26-XU-LT and 77002-26-76-RT are not supported in the medical record. 
Specifically, code 77002 has a bilateral surgery indicator of "0", which means the procedure must be reported 
with "1" unit of service. There is no additional payment for the code if reported as a unilateral or bilateral 
procedure because of anatomy or physiology. Alternatively, the code descriptor may specifically state that the 
procedure is a unilateral procedure, and there is a separate code for a bilateral procedure. Based on this 
information, we decided that Medicare rules for coverage of codes 77002-26-XU-LT and 77002-26-76-RT have not been met. Therefore, we decided that the Plan does not have to pay for the Fluoroscopic guidance for 
needle placement (77002-26-XU-LT and 77002-26-76-RT) provided on December 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The provider says this procedure fills a treatment gap for patients that do 
not receive adequate relief from traditional conservative methods and do not have instability to indicate fusion 
is the appropriate treatment. The provider also says the procedure has received FDA clearance. The Plan denied 
your request. The Plan says the requested procedure is not medically reasonable or necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested procedure is considered experimental and therefore 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on May 2, 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 there is no documentation in the medical records which supports an exceptional or unique 
circumstance that requires anesthesia. 
 
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 services. 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, there is no documentation in the medical records which supports an exceptional or 
unique circumstance requiring anesthesia. The review has determined that anesthesia was not needed during the 
lumbar transforaminal epidural steroid injection. 
 
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 pay for anesthesia services provided to the enrollee on May 2, 2022.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services on February 23, 2021, and February 25, 2021, through 
February 27, 2021. We decided that the Plan does not have to pay for 99232-25 for February 24, 2021.  
 
You asked the Plan to pay for inpatient hospital services (CPT code(s): 99222, 99232-25 and 99232) provided 
from February 23, 2021, through February 27, 2021. You say that the claim should be paid. The Plan says that 
the services are not supported by the records. 
 
We decided that the Plan has to pay for the services on February 23, 2021, and February 25, 2021, 
through February 27, 2021.  
 
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 services on February 23, 2021, and 
February 25, 2021, through February 27, 2021. Our reviewer says that the medical documentation supports the 
initial inpatient code 99222 for date of service February 23, 2021, but also supports this being billed with 
modifier 57 due to surgery being discussed and decided to happen within 24 hours. Furthermore, the medical 
documentation does support subsequent visits for the remainder of the enrollee's stay from February 25, 2021, 
through February 27, 2021. 
 
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 on February 23, 2021, and February 25, 2021, through February 27, 
2021, have been met. Therefore, we decided that the Plan has to pay for the services on February 23, 2021, and 
February 25, 2021, through February 27, 2021.  
 
We also decided that the Plan does not have to pay for 99232-25 for February 24, 2021. 
 
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 99232-25 for February 24, 2021. Our 
reviewer says that the medical documentation does not support the use of procedure code 99232-25 for 
February 24, 2021. This would be considered a pre-op visit since there was a procedure performed of 49239 
with a 0-day global and therefore, not billable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99232-25 for February 24, 2021, have not been met. Therefore, we decided that 
the Plan does not have to pay for 99232-25 for February 24, 2021. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for general anesthesia (D9222 and D9223) provided by an out-
of-network provider on May 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that your nerve endings are sensitive. You say that 
you need these services done. The Plan denied your request. The Plan says the dental services were received 
from an out-of-network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for general anesthesia (D9222 and D9223) provided by an out-of-network provider on May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure fills a treatment gap for 
those patients that do not receive adequate relief from traditional conservative methods and don't have 
instability to indicate that fusion is the appropriate treatment. You say that the enrollee has tried and failed 
conservative treatment without success. You also say that this procedure has received FDA clearance. The Plan 
denied your request. The Plan says the requested procedure is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested Intracept procedure is considered experimental and therefore 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that the medical records support the claim. The Plan 
denied your request. The Plan says the billed codes cannot be verified. 
 
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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services provided on August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete mandibular denture realignment (D5751) 
provided by a participating provider on June 23, 2022. 
 
You asked the Plan to pay for a complete mandibular denture realignment. You say that your bottom dentures 
are very loose. The Plan denied your request. The Plan says the rendered dental service 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 pay for a 
complete mandibular denture realignment (D5751) provided by a participating provider on June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant for tooth #18 (D6010). 
 
You asked the Plan to pre-approve an endosteal implant. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this service is not covered by the Plan's dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
endosteal implant for tooth #18 (D6010).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 24, 2022 billed with 
codes 81162, 81201, 81209, 81218, 81292, 81295, 81298, 81307, 81314, 81317, 81321, 81334, 81351, 81406 
and 81437. 
 
You asked the Plan to pay for the genetic testing billed. You say that please have a look at the attachment and 
reconsider the charges which were previously denied. The Plan denied your request. The Plan says does not 
meet Medicare NCD/LCD criteria. Screening genetic testing is not a covered benefit. 
 
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 
March 24, 2022 billed with codes 81162, 81201, 81209, 81218, 81292, 81295, 81298, 81307, 81314, 81317, 
81321, 81334, 81351, 81406 and 81437.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the visit (99205) provided on April 19, 2022. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
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 99205 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using time for code selection, 60-74 minutes of 
total time is spent on the date of the encounter".  
We find that CPT code 99205 is not supported in the medical record. Specifically, the records show that the 
enrollee was seen by this provider on March 4, 2022. As such, it is inappropriate to bill a new patient visit for 
the requested services. Based on this information, we decided that Medicare rules for coverage of the visit have 
not been met. Therefore, we decided that the Plan does not have to pay for the visit (99205) provided on April 
19, 2022.