Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service August 8, 
2022. 
 
You asked the Plan to pay for procedure code 99153. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 3 for CPT code 99153. This means there 
is only a technical component for the CPT code. This code is not payable if furnished to patients in a hospital 
outpatient department. Based on this information, we decided that Medicare rules for coverage of procedure 
code 99153 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99153 billed for date of service August 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2313, E2377) and a 
power seat system (E1012). 
 
You asked the Plan to pre-approve the upgraded electronics and a power seat system. You say that you are 
requesting reconsideration of the denied authorization. The Plan denied your request. The Plan says that the 
requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that upgraded electronics are covered when it is medically 
necessary for the enrollee to control the power options through the joystick. The rules also say that the 
enrollee's medical record must contain sufficient documentation to substantiate the necessity for the type and 
quantity of items ordered. 
 
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 upgraded electronics and a power 
seat system. Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that 
you have adequate strength to manage the standard power drive controls. The provided records from the 
examining physician do not document that you have a musculoskeletal condition or the presence of a cast or 
brace which prevents 90-degree flexion at the knee or have significant edema of the lower extremities that 
requires a power elevating leg rest. A letter of medical necessity was submitted on June 8, 2023, reporting the 
need for the power seat system - center mount power elevating leg rests for edema but edema is not 
documented by the examining physician. 
 
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 upgraded electronics and a power seat system have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2313, E2377) and a 
power seat system (E1012).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service August 23, 
2022. 
 
You asked the Plan to pay for procedure code 81345. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 81345 is bundled into 
payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service August 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the drive wheel color inserts (K0108). 
 
You asked the Plan to pre-approve the drive wheel color inserts. The Plan denied your request. The Plan says 
that the requested color inserts 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. Therefore, we 
decided that the Plan does not have to pre-approve the drive wheel color inserts (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code P9603 billed for date of service January 12, 
2023. 
 
You asked the Plan to pay for procedure code P9603. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code P9603 is: Travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; prorated miles actually travelled. 
 
We find that CPT code P9603 is not supported in the case record. Specifically, no documentation has been 
provided to support reimbursement for travel for laboratory specimen collection. The record shows that the 
Plan made several attempts to obtain the necessary documentation without success. Based on this information, 
we decided that Medicare rules for coverage of procedure code P9603 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code P9603 billed for date of service January 12, 
2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95907 billed for date of service October 4, 
2021.   

You asked the Plan to pay for procedure code 95907. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 95907 is bundled into payment for code 
95868. 
 
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 95907 
is a column II code to column I code 95868 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 95907 billed for date of service October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral/facial photographic images (D0350) provided on 
December 20, 2022. 
 
You asked the Plan to pay for the photographic images. You say that you were advised that this service would 
be covered. The Plan denied your request. The Plan says that oral/facial photographic images (D0350) are 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested photographic images are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
oral/facial photographic images (D0350) provided on December 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87631 and 99072 provided on October 10, 
2022.  
 
You asked the Plan to pay for procedure codes 87631 and 99072. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim for procedure code 
87631 did not include the required unique identifier. Additionally, procedure code 99072 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. Medicare rules also say that providers must 
report services correctly. Providers must report services with the appropriate procedure code. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Additionally, we find that procedure code 99072 has a status indicator of B on the Physician Fee 
Schedule. This means that procedure code 99072 is not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 87631 and 99072 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87631 and 99072 provided on October 10, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481, 87653, and 87798 billed for date of 
service July 13, 2022. 
 
You asked the Plan to pay for procedure code 87481, 87653, and 87798. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for codes 87481, 87653, and 87798 is 
bundled into payment for code 87801. 
 
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 codes 
87481, 87653, and 87798 are column II codes to column I code 87801. 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 87481, 87653, and 87798 
billed for date of service July 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G6002 billed for date of service March 10, 
2022.   

You asked the Plan to pay for procedure code G6002. You say that the records show that this service was billed 
correctly. The Plan denied your request. The Plan says payment for code G6002 is bundled into payment for 
code 77301. 
 
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 G6002 
is a column II code to column I code 77301 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 G6002 billed for date of service March 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service September 7, 
2022. 
 
You asked the Plan to pay for procedure code 81345. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service September 7, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve code 64495 - Injection(s), diagnostic or therapeutic 
agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance 
(fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (Level L4-L5 bilateral). 
 
You asked the Plan to pre-approve a third level facet joint injection. You say that the requested facet joint 
injections are medically necessary. The Plan denied your request. The Plan says the requested third level facet 
joint injection is not considered medically necessary. 
 
The Plan follows Medicare rules.  
 
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 code 64495 - injection(s), diagnostic or 
therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image 
guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (Level L4-L5 bilateral). Our 
reviewer says that a third level facet joint injection is not considered medically necessary. Our physician 
reviewer found Medicare says facet joint procedures performed after anterior lumbar interbody fusion are 
considered not reasonable and necessary. Therefore, only two levels not involving the fusion level are 
indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 64495 - injection(s), diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or 
sacral; third and any additional level(s) (Level L4-L5 bilateral) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve code 64495 - injection(s), diagnostic or therapeutic agent, paravertebral 
facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (Level L4-L5 bilateral).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three (3) lumbar medical branch blocks.  
 
You asked the Plan to pre-approve three (3) lumbar medical branch blocks. You say that three (3) lumbar 
medical branch blocks are medically necessary. The Plan denied your request. The Plan says per Medicare 
rules, only two joints are allowed to be injected per session.  
 
The Plan follows Medicare rules.  
 
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 three (3) lumbar medical branch blocks. 
Our reviewer says that three (3) lumbar medical branch blocks are not considered medically necessary. Our 
physician reviewer found that in this case, the enrollee has non-facet pathology (L3 lumbar fracture) and spinal 
stenosis with neurogenic claudication. The review has determined that the requested third lumbar medial 
branch blocks do not meet the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of three (3) lumbar medical branch blocks have not been met. Therefore, we 
decided that the Plan does not have to pre-approve three (3) lumbar medical branch blocks.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory polymerase chain reaction (PCR) panel 
provided on June 3, 2022, billed with codes 87633, 87541, 87841, 87481, 87561, 87551, 87798. 
 
You asked the Plan to pay for the laboratory testing billed. You say that please find the attached medical 
records and you request for review and processing of the claim for payment. 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 laboratory testing 
billed have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory 
polymerase chain reaction (PCR) panel provided on June 3, 2022, billed with codes 87633, 87541, 87841, 
87481, 87561, 87551, 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93015, 99215, A9500, J2785 rendered on 
October 7, 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 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 93015:

Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with supervision, interpretation and report

CPT 99215:

Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter

Healthcare Common Procedure Coding System (HCPCS) A9500:

Technetium tc-99m sestamibi, diagnostic, per study dose

HCPCS J2785:

Injection, regadenoson, 0.1 mg


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 not supported by the medical records. Our reviewer found that codes 93015, A9500, and J2785 are not supported. The documentation for this date of service does not contain any report or account of a stress 
test (93015) or the pharmacologic agents used to perform one (A9500 and J2785). There is no evidence that 
these services were performed as billed. CPT code 99215 is not supported. The documentation does not contain 
a high level of medical decision making. The decision making involved adjusting medication dosages, which is 
considered moderate decision making.. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 93015, 99215, A9500, J2785 rendered on October 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for spine surgery. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that you are proceeding with surgery. The 
Plan denied your request. The Plan says the clinical value and effectiveness of this have not been established. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate for spine surgery.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97116, 97112, and 97110 for date of service 
December 15, 2022, to December 20, 2022. 
 
You asked the Plan to pay for procedure codes 97116, 97112, and 97110. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 16, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure codes 97116, 97112, and 97110 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 97116, 97112, 
and 97110 for date of service December 15, 2022, to December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cleaning and inspection of a removable complete denture, 
maxillary (D9932) provided on January 26, 2023. 
 
You asked the Plan to pay for the cleaning and inspection of removable complete denture. You say that the 
provider did not advise you that the cleaning and inspection of your dentures were not covered. You also say 
that had you known you would have declined the service. The Plan denied your request. The Plan says there is 
no coverage for the cleaning and inspection of removable complete denture, maxillary (D9932). 
 
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 cleaning 
and inspection of the removable complete denture, maxillary (D9932) provided on January 26, 2023.