Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 76641 billed for date of service September 16, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says that the code has an MUE value of 1. 
 
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 76641 is ultrasound, breast, unilateral, real time with 
image documentation, including axilla when performed; complete. We find that CPT code 76641 has an MUE 
value of 2. The claim shows that code 76641 was billed on 2 separate claim lines using the RT and LT modifier 
as required. 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 76641 billed for date of service 
September 16, 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the denosumab injection and administration provided on January 27, 
2022. 
 
You asked the Plan to pay for the denosumab injection and administration. You say that your provider advised 
you to see a specialist as soon as possible due to your health condition. The Plan denied your request. The Plan 
says that an authorization was required prior to services rendered. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan does not say in clear and accurate terms 
how much you should expect to pay for Medicare-covered Part B drugs.  
 
The Plan says there was no authorization for the in-network services. We looked at your contract with the Plan. 
The Evidence of Coverage clearly states that prior authorization is only required for certain in-network services 
and does not confirm that authorization is always required for Medicare-covered Part B drugs. This means that 
the Plan has not provided a valid reason for denying payment of the denosumab injection and administration. It 
is the burden of the Health Plan to substantiate their denial with evidence. In this case, the denial has not been 
substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the denosumab 
injection and administration provided on January 27, 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: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 76641 billed for date of service September 6, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says that code 76641 has an MUE value of 1. 
 
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 76641 is ultrasound, breast, unilateral, real time with 
image documentation, including axilla when performed; complete. We find that CPT code 76641 has an MUE 
value of 2. The claim information show that 1 unit of service was billed with modifier RT on 1 claim line and 1 
unit of service and modifier LT was billed on the second claim line. 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 76641 billed for date of service September 6, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a visit for dental care with an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to continue to see the same 
dentist. The Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
  You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, dental 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 pre-approve a visit for dental care with 
an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation services. 
 
You asked the Plan to pre-approve SI joint radiofrequency ablation services. You say that this procedure is 
medically reasonable and necessary. The Plan denied your request. The Plan says the requested services are 
considered experimental/investigational. 
 
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 SI joint radiofrequency ablation 
services. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that you are a 71-year-old female with chronic low back 
pain with partial relief from pain medication. According to the literature, sacral lateral nerve branch blocks 
and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered 
experimental and investigational. Radiofrequency ablation for denervation, whether performed using 
traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not medically 
necessary. The requested SI joint radiofrequency ablation has not been proven effective and is considered 
experimental/investigational. The review has determined that the requested SI joint RFA is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint radiofrequency ablation services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on July 26, 
2021. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that you should not have a copay 
for this service. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for ambulance services. 
 
You have been asked to pay a $100 copayment for an ambulance ride. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ambulance ride 
provided on July 26, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 13, 2022, 
through May 11, 2022. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says there is not a valid NOA claim on file for the Admit Date submitted. 
 The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the home health services have not been met. Admit Date submitted 
on the claim is April 13, 2022. Invalid NOA claim submitted on Bill Type 322. If the provider determines that 
a billing error occurred during the initial submission of the denied claim, the Plan will accept a submission of a 
corrected claim to consider services for payment. Therefore, we decided that the Plan does not have to pay for 
the home health services provided from April 13, 2022, through May 11, 2022.
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 7, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this service was medically necessary. 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 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the request is not medically necessary because the 
enrollee is receiving the care they need in the hospital where they are now and there is no need to transfer to the 
LTACH at this time. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records do not indicate that the enrollee requires services that she is not 
currently receiving but that would be available at the LTACH facility.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for office visit provided on May 26, 2022, to 
June 10, 2022. 
 
You asked the Plan to waive the coinsurance for office visit. You say that you have met your maximum out-of-
pocket amount, so you should not have to pay for these visits. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 15% 
coinsurance for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers and Physician/practitioner services, including doctors office visit. 
 
You have been asked to pay 15% coinsurance for office visit. This item/service falls within the outpatient 
surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers and 
Physician/practitioner services, including doctors office visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for office visit provided on May 26, 2022, to June 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on February 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 the dental services on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the abutment supported porcelain fused to a metal 
crown (D6060x2) and the prefabricated abutment (D6056x2). 
 
You asked the Plan to pre-approve the abutment supported porcelain fused to a metal crown (D6060x2) and the 
prefabricated abutment (D6056x2). You say that you are appealing this denial. The Plan denied your request. 
The Plan says the services are not covered 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 the 
abutment supported porcelain fused to a metal crown (D6060x2) and the prefabricated abutment (D6056x2).
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 7, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this service was medically necessary. 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 7, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99283 billed for date of service August 22, 
2022. 
 
You asked the Plan to pay for procedure code 99283. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 99283 is bundled into payment for 
code 99284. 
 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 99283 is a column II code to column I code 99284. 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 99283 
billed for date of service August 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 5, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that this should be paid for. 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 August 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulator supplies (A4595) provided on June 10, 
2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that these items were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for electrical stimulator supplies 
(A4595) provided on June 10, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure codes 27138, 27236) provided to the 
enrollee on October 12, 2021. 
 
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 that the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
the denied codes is: 
 
CPT 27138: 
 
Revision of total hip arthroplasty; femoral component only, with or without allograft 
 
CPT 27236: 
 
Open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the records do support that CPT 
27138: revision of total hip arthroplasty, femoral component only, with or without allograft was rendered in 
this case. The procedure in detail cites the hip was dislocated and the proximal femoral stem was extracted. 
Proximal bodies were trialed and many different sizes were tried. The 20mm provided a good stable hip with 
the limb lengths being very close to equal. The real implants were placed. Therefore, the documentation 
supports the use of CPT 27138. Additionally, the records do support that CPT 27236: open treatment of 
femoral fracture, proximal end, neck, internal fixation or prosthetic replacement was rendered in this case. The 
procedure in detail cites two cables were then placed, one below the lesser trochanter and one above the lesser 
trochanter, tightened them to 50kg of pressure. They were crimped and went through range of motion. 
Therefore, the documentation does support the use of CPT 27236. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
surgical services (procedure codes 27138, 27236) provided to the enrollee on October 12, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies coded 95907 and the needle 
electromyography services coded 95886 provided on June 28, 2022. 
 
You asked the Plan to pay for the nerve conduction studies and the needle electromyography services. You say 
that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are 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.  

We find that CPT codes 95907 and 95886 are not supported in the medical record. Specifically, The technical 
report did not include documentation of a nerve conduction studies; for 1-2 studies; therefore, code 95907 is 
not supported. The technical report did not include documentation of a complete needle electromyography, per 
each extremity with related paraspinal areas when performed, done with nerve conduction, amplitude and 
latency/velocity study; for five or more muscles studied, innervated by three or more nerves or four or more 
spinal levels (listed separately in addition to code for primary procedure); therefore, code 95886 cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of the nerve conduction 
studies and the needle electromyography services have not been met. Therefore, we decided that the Plan does 
not have to pay for the nerve conduction studies coded 95907 and the needle electromyography services coded 
95886 provided on June 28, 2022.