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

 
We decided that the Plan has to pay for code A4222, defined as infusion supplies for external drug infusion 
pump, per cassette or bag, billed for dates of service April 29, 2023, through May 4, 2023. 
 
You asked the Plan to pay for A4222. You say that A4222 should be covered because it is appropriately coded 
and payable under the Medicare Fee Schedule. The Plan denied your request. The Plan says that A4222 is 
denied because it has a medical unlikely edit (MUE) value of 0 and is therefore not eligible for reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that external infusion pumps are covered under the 
Durable Medical Equipment (DME) benefit. Supplies used with an external infusion pump, such as A4222, are 
covered during the period of covered use of an infusion pump. 
 
We looked at the file and Medicare rules. According to LCD L33794, A4222 is a covered code under DME 
benefits. We confirmed that code A4222 is not listed on the DME medically unlikely edit (MUE) table. The 
code not being listed in the table would not imply that it is not covered, though, as there are many codes in the 
DME table that do list an MUE of 0. We also confirmed that A4222 does have a DME fee schedule amount 
assigned, which would not be the case were it invalid or never eligible for reimbursement. Based on this 
information, we decided that Medicare rules for coverage of A4222 have been met. Therefore, we decided that 
the Plan has to pay for code A4222, defined as infusion supplies for external drug infusion pump, per cassette 
or bag, billed for dates of service April 29, 2023, through May 4, 2023.  
 
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 a core build-up (D2950) provided on July 18, 2023. 
 
You asked the Plan to pay for D2950. You say that this should be covered because it is part of the crown 
installation. The Plan denied your request. The Plan says this 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 core 
build-up (D2950) provided on July 18, 2023.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 87338. We decided that the Plan does not have to pay 
for procedure code 87798-XU.  
 
You asked the Plan to pay for the lab testing billed for date of service June 19, 2023. You say that the lab 
services were provided without prejudice. The Plan says that one code must be submitted for a panel. 
 
We decided that the Plan has to pay for procedure code 87338.  
 
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 87338 is infectious agent antigen detection by 
immunoassay technique (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], 
fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative; 
Helicobacter pylori, stool. 
 
We find that CPT code 87338 is supported in the medical record. The records show that Helicobacter pylori 
stool testing was ordered and provided. This testing was not part of a panel. This was an additional stool test 
ordered apart from the diarrheal panel test. Based on this information, we decided that Medicare rules for 
coverage have been met. Therefore, we decided that the Plan has to pay for procedure code 87338 billed for 
date of service June 19, 2023.  
 
We also decided that the Plan does not have to pay for procedure code 87798-XU. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
We find that code 87798, billed with the XU modifier, is not supported. The records do not show that this 
testing was an unusual non-overlapping service, or that it was a separate and distinct service. There are no code 
edits for this code and any other code billed on the claim. The use of the modifier is not payable in this case. 
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 87798-XU billed for date of service June 19, 
2023. 
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for 4 units of the blood glucose test strips (A4253). 
 
You asked the Plan to pay for the blood glucose test strips. You say that the enrollee test 4 times a day and was 
provided a 3-month supply. The Plan denied your request. The Plan says that the denial of payment for these 
items is correct, because they are over the maximum allowable for the period. 
 
The Plan must follow Medicare rules. The rules say that additional test strips over the maximum allowable may 
be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced in the 
Medicare rules section. 
 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 blood glucose test strips. Our reviewer 
says that the additional test strips are medically necessary. Our physician reviewer found that the provider has 
indicated that the enrollee is prescribed 4 strips a day and the enrollee is followed closely and is checking 4 
times a day the additional quantity of 4 strips a day meets medical necessity criteria above. While it is not 
completely clear why the enrollee needs to check 4 time a day, many patients and providers use this data to 
provide feedback (both positive and negative) on an ongoing daily basis with an appropriate diet; hence this is 
medically justified in this case. 
 
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 blood glucose test strips have been met. Therefore, we decided that the Plan 
has to pay for 4 units of the blood glucose test strips (A4253).  
 
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 procedure code G0453 billed for date of service May 17, 
2023. 
 
You asked the Plan to pay for procedure code G0453. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code G0453 is bundled into 
payment for code 95813. 
 
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 G0453 
is a column II code to column I code 95813. 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 G0453 billed for date of service May 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
July 29, 2022, and billed with codes 87150, 87481, 87653, 87798, 87801, and 87641. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on July 29, 2022, and billed with codes 87150, 87481, 87653, 87798, 87801, and 87641.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H0005 billed for date of service July 13, 
2023. 
 
You asked the Plan to pay for procedure code H0005. You say that the enrollee had been receiving services 
prior to joining the Plan. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code H0005 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H0005 is not valid for Medicare purposes. Medicare uses other codes to represent this service 
(i.e., G2011, G0396, or G0397.) Based on this information, we decided that Medicare rules for coverage of 
procedure code H0005 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code H0005 billed for date of service July 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on June 9, 2023. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says the PCR testing is considered unproven and 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 pay for the urine PCR panel testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the standard of care for the evaluation of urinary incontinence is urinalysis with 
urine culture and sensitivity. The PCR testing is considered unproven and not medically necessary. The review 
indicates that the items/services at issue in this case were 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 the urine PCR panel testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on June 9, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service June 12, 
2023. 
 You asked the Plan to pay for procedure code 76942. The Plan denied your request. The Plan says payment for 
code 76942 is bundled into payment for code 20606. 
 
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 76942 
is a column II code to column I code 20606. 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 76942 billed for date of 
service June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on August 17, 2023. 
 
You asked the Plan to pay for OIVIT services. The Plan denied your request. The Plan says the billed services 
are not supported. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services provided on August 17, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied IRF services and that the services requested are medically necessary. The Plan denied your request. The 
Plan says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee requires treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program at least three hours a day and five days a week, or 15 
hours over seven consecutive days. The enrollee is currently requiring moderate assistance for bed mobility and 
transfers as well as ambulation with the assistance of a walker. The enrollee requires maximal assistance with 
daily activities, including dressing and toileting. The enrollee has had a decline from their baseline level of 
function and would benefit from the intensity of therapies provided on acute inpatient rehabilitation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied IRF services and that the services requested are medically necessary. The Plan denied your request. The 
Plan says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the complexity of the enrollees nursing medical and rehabilitation needs does require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted to the 
hospital on November 1, 2023, for removal of right sided ankle hardware that was exposed and non-healing. 
They ultimately required a right transtibial amputation on November 13, 2023. The enrollee developed hypoxia 
post-operative required BiPAP for acute on chronic respiratory failure and is requiring supplemental oxygen. 
Given the complexity of their medical issues they would benefit from the oversight of a rehabilitation physician 
as well as rehabilitation nursing care for wound care and management of their PEG-tube. The enrollee's 
medical and rehabilitation needs do require the intensive interdisciplinary approach provided on acute inpatient 
rehabilitation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the infectious agent antigen detection by immunoassay 
technique (87389).  
You asked the Plan to pre-approve the infectious agent antigen detection by immunoassay technique. You say 
that the service is medically necessary. The Plan denied your request. The Plan says this is a screening test and 
not covered by Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, 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 infectious agent antigen detection 
by immunoassay technique. Our reviewer says that the service is not medically necessary. Our physician 
reviewer found that the test was requested for screening purposes. 
 
The test at issue in this appeal, the infectious agent antigen detection by immunoassay technique, is being 
requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. 
Therefore, we decided that the Plan does not have to pre-approve the infectious agent antigen detection by 
immunoassay technique (87389).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight Psychotropic test (81479) provided October 31, 
2022. 
 You asked the Plan to pay for the genetic testing. You say that no basis exists for a Medicare Advantage Plan 
to deny coverage of a medically necessary service that is covered by Medicare. The Plan denied your request. 
The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The test is not covered by Medicare per DEX Diagnostics. GeneSight 
Psychotropic has not been shown to be useful, is not considered medically necessary and appropriate, is not 
covered by Medicare and cannot be approved. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
GeneSight Psychotropic test (81479) provided October 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (33207) provided on June 21, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the required modifier 
was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier KX must be used as an attestation by 
the practitioner and/or provider of the service that documentation is on file verifying the patient has a 
symptomatic arrhythmia or a high potential for progression of the rhythm disturbance requiring a permanent 
pacemaker for Groups I and II. 
 
We looked at the file and Medicare rules. In this case, modifier KX was not used as required when the services 
are billed with diagnosis code I44.2. 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 the services 
(33207) provided on June 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the enrollee has tried and failed 
conservative measures. The Plan denied your request. The Plan says this procedure is 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without 
facet joint disease or stenosis. The cause of pain is not clear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.