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

 
We decided that the Plan does not have to pay for procedure codes 93308, 93321, and 93325 billed for date of 
service October 27, 2022. 
 You asked the Plan to pay for procedure codes 93308, 93321, and 93325. You say that the claim was billed 
correctly and should be paid. The Plan denied your request. The Plan says payment for codes 93308, 93321, 
and 93325 are bundled into payment for code 93306. 
 
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 93308, 
93321, and 93325 are column II codes to column I code 93306. 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 codes 93308, 93321, and 93325 
billed for date of service October 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673) provided 
on October 20, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this item was medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for a pneumatic compression device (E0675, E0673) provided on October 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the manual wheelchair and accessories. 
 
You asked the Plan to pre-approve the wheelchair. You say that please consider reversing the denial decision 
for this enrollee's request for a customized wheelchair. The Plan denied your request. The Plan says Medicare 
does not cover DME in a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that 
the Plan does not have to pre-approve the manual wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057) and an abutment 
supported to a crown (D6061) for tooth #5 provided on November 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to get reimbursed for your 
maximum allowable of $1,500. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because the custom fabricated abutment and an abutment supported to a crown 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 custom 
fabricated abutment (D6057) and an abutment supported to a crown (D6061) for tooth #5 provided on 
November 7, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the enteral formula, nutritionally complete with intact 
nutrients (B4150). 
 
You asked the Plan to pay for the enteral formula. You say that the enrollee has previously been using these 
shakes as a reliable source of nutrition. You believe the enrollee will benefit from having these shakes. The 
Plan denied your request. The Plan says orally administered nutrition products are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pay for are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pay for the enteral formula, nutritionally complete with intact nutrients (B4150).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skyrizi. 
 
You asked the Plan to pre-approve Skyrizi. The Plan denied your request. The Plan says this drug is not 
covered under the enrollee's Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Skyrizi.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve Gemtesa. The Plan denied your request. The Plan says this drug is not 
covered under the enrollee's Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel rendered on January 28, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says respiratory panels of six or more pathogens are not covered. 
 
The Plan must follow Medicare rules. The rules say that respiratory pathogen panels with more than 5 
respiratory pathogens performed in the Part B outpatient setting are considered not medically necessary. 
 
We looked at the file and Medicare rules. The file shows that more than 5 respiratory pathogens were tested. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the respiratory pathogen panel rendered on 
January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer crown - porcelain/ceramic (D6740), core buildup 
(D2950) and periodontal scaling and root planning (D4341, D4342) provided on November 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for periodontal scaling, root planning and retainer crown -porcelain/ceramic 
has already been exhausted. The Plan says your request for a core buildup 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, certain limitations apply. The record 
shows your benefit for periodontal scaling and root planning was exhausted on date of service September 29, 
2020. Therefore, we decided that the Plan does not have to pay for retainer crown - porcelain/ceramic (D6740), 
core buildup (D2950) and periodontal scaling and root planning (D4341, D4342) provided on November 7, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upgraded power wheelchair (PWC). 
 
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 chair was not requested with the appropriate code. 
 
The Plan must follow Medicare rules. Medicare rules say that correct coding is required for DME approval. 
 
We looked at the file and Medicare rules. The file shows that the power wheelchair at issue was not requested 
with the proper procedure code. 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 an 
upgraded power wheelchair (PWC).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 9, 2022, billed with 
codes 81191, 81317, 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301 and 
81311. 
 
You asked the Plan to pay for the genetic testing billed. You say that this is a medically necessary test and 
should be covered. 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 
February 9, 2022, billed with codes 81191, 81317, 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 
81295, 81298, 81301 and 81311.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0425 billed for date of service December 
18, 2022. 
 
You asked the Plan to pay for procedure code A0425. You say that the patient was transported to the nearest 
facility who could treat them. 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 units exceed the MUE on a single line item.  
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 251 units of 
this code on a single line on your claim, exceeding the MUE. In order for excess units to be covered, they must 
be submitted on an additional claim line with an appropriate modifier. Based on this information, we decided 
that Medicare rules for coverage of procedure code A0425 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code A0425 billed for date of service December 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76775 billed for date of service September 
22, 2022. 
 You asked the Plan to pay for procedure code 76775. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 76775 is bundled into payment for code 
76770. 
 
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 76775 
is a column II code to column I code 76770. 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 76775 billed for date of service September 22, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) implant trial. 
 
You asked the Plan to pre-approve a SCS implant trial. 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 follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless certain 
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 a SCS implant trial. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found this patient does not have an 
evidence-based indication for a SCS trial. The request is not medically reasonable and 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 a SCS implant trial have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a spinal cord stimulator (SCS) implant trial.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Infuse BMP allograft for cervical-thoracic spinal fusion 
surgery. 
 
You asked the Plan to pre-approve Infuse BMP allograft. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Infuse BMP allograft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found infuse BMP is experimental in the thoracic spine and not FDA approved. Autograft is 
gold standard.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Infuse BMP allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Infuse BMP allograft for cervical-thoracic spinal fusion surgery.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination, chest; single view rendered on 
October 31, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the place of service is inconsistent with the patient being a registered inpatient. 
 
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 71045 is "Radiologic examination, chest; single view." 
 
We find that CPT code 71045 is not supported in the medical record. Specifically, as the enrollee was 
registered inpatient, the place of service that was billed - 23 for emergency room - is inappropriate. 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 a radiologic examination, chest; single view rendered on October 
31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99215 billed for date of service November 8, 2022. 
 
You asked the Plan to pay for code 99125. You say that this service was rendered, so this claim should be paid. 
The Plan denied your request. The Plan says you billed with an incorrect principal diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that that diagnosis code M4156 is on the 
Unacceptable Principal Diagnosis list. This means that this diagnosis cannot be listed on a claim as the 
principal diagnosis. You billed this claim with a principal diagnosis of M4156, which is not allowed per 
Medicare rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99125 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99215 billed for date of service November 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on October 11, 2022. 
 You asked the Plan to pay for the refraction. You say that you were told you that the Plan did not see why the 
service was denied. The Plan denied your request. The Plan says the refraction is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when performed as a part of the routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was done as a part of a medical eye exam. 
Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met. 
Therefore, we decided that the Plan does not have to pay for the refraction provided on October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care (99225) provided on August 9, 2022. 
 
You asked the Plan to pay for observation care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 99225 is Initial observation care, per day, for the 
evaluation and management of a patient. 
 
We find that CPT code 99225 is not supported in the medical record. Specifically, the provided records do not 
show that the patient was admitted for observation. Based on this information, we decided that Medicare rules 
for coverage of observation care have not been met. Therefore, we decided that the Plan does not have to pay 
for observation care (99225) provided on August 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service November 
18, 2022. 
 You asked the Plan to pay for procedure code 93010. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 93010 is bundled into payment for code 
78431. 
 
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 93010 
is a column II code to column I code 78431. 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 93010 billed for date of service November 18, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300), push handles 
(K0108) and foot plate (K0108). 
 
You asked the Plan to pre-approve a power seat elevation feature, push handles and foot plate. You say that 
you need these features. The Plan denied your request. The Plan says these items do not serve a medical 
purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300), push handles 
(K0108) and foot plate (K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided by a Licensed Surgical 
Assistant (LSA). 
 
You asked the Plan to pay for the LSA services. You say that the primary surgeon and the facility are in-
network, and the surgery code allows for a surgical assistant. The Plan denied your request. The Plan says you 
are not a valid provider type to bill Medicare. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
 In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided 
by a Licensed Surgical Assistant (LSA).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that the medication is for post operative symptoms 
from anesthesia. The Plan denied your request. The Plan says this drug does not fall under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron.  Benefits for Ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says this drug is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Botox.  
 
Benefits for Botox may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.