Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS system. 
 
You asked the Plan to pre-approve the requested services. You say that the system will monitor the enrollee's 
pulmonary pressures and volume. The Plan denied your request. The Plan says the device remains of uncertain 
value.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has recurrent congestive heart failure. The system was requested to help 
improve fluid management and symptoms. Published expert opinion in the cardiology literature is supportive of 
the clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical 
studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. 
As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary 
in this enrollees clinical management. 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 95937-26 billed for date of service June 21, 2023. 
 
You asked the Plan to pay for code 95937-26. You say that medical records were provided to support payment. 
The Plan denied your request. The Plan says code 95937-26 is not supported by the medical record. The 
records submitted indicate that train-of-four testing was performed. Train-of-Four testing does not fit the 
criteria for this code. 
 
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 95937-26 is Neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
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 code 95937-26. Our reviewer says that code 95937-26 is not supported by the medical record. Our reviewer found there is a more appropriate procedure code to represent 
the services provided, which would code this service to the highest specificity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 95937-26 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 95937-26 billed for date of service June 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  a right-sided L3-4 and L4-5 minimally invasive (MIS) 
transforaminal lumbar interbody fusion (TLIF). 
 
You asked the Plan to pre-approve  a right-sided L3-4 and L4-5 minimally invasive (MIS) transforaminal 
lumbar interbody fusion (TLIF).. You say that the services is medically necessary. The Plan denied your 
request. The Plan says the services is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a right-sided L3-4 and L4-5 minimally 
invasive (MIS) transforaminal lumbar interbody fusion (TLIF). Our reviewer says that the requested service is 
not considered medically reasonable and necessary in this case. Our physician reviewer found there are limited 
large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception.  
 
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 right-sided L3-4 and L4-5 minimally invasive (MIS) transforaminal lumbar 
interbody fusion (TLIF). have not been met. Therefore, we decided that the Plan does not have to pre-approve  
a right-sided L3-4 and L4-5 minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93229 billed for date of service March 1, 
2023. 
 
You asked the Plan to pay for the billed services. You say that documentation was provided for review. The 
Plan denied your request. The Plan says an incorrect date of service was 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 code 93229 is external mobile cardiovascular telemetry with 
electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of 
accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events 
transmitted to a remote attended surveillance center for up to 30 days. 
 
 We find that CPT code 93229 is not supported in the medical record. The records show that the monitoring 
services were provided from February 28, 2023, to March 1, 2023. The date of service must be reported as the 
date the enrollee was initially placed on the monitor. Based on this information, we decided that Medicare rules 
for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 93229 billed for date of service March 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composites (D2330) for tooth #24 and #26 
 
You asked the Plan to pay for D2330. You say that these services were not cosmetic. The Plan denied your 
request. The Plan says the rendered dental services were cosmetic in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of D2330 have been met. Dental x-rays 
were not provided to verify whether or not the requested dental work was cosmetic in nature. Therefore, we 
decided that the Plan does not have to pay for resin-based composites (D2330) for tooth #24 and #26
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service July 13, 
2023.  
 You asked the Plan to pay for procedure code 86077. You say that the second unit of this code is 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 86077 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 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service July 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 for date of service February 2, 2023. 
 
You asked the Plan to pay for procedure code 99232. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules also say that the use of modifier 77 with an evaluation and management code is inappropriate. 
 
 
 
 We looked at the file and Medicare rules. In this case, a modifier 77 was attached to code 99232. Code 99232 
is an evaluation and management code. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99232 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99232 for date of service February 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on March 1, 2023, billed with 
codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81403, 81404, 81405, 81406, 81407, 
81408, and 81479. 
 You asked the Plan to pay for the billed testing. You say that there is no diagnosis code limitation in the 
guidelines. 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and Medicare rules. This NGS panel was not billed with a single code as required. The 
claim was billed with the laboratory POS code. The records do not support that the sample was taken in a 
laboratory setting. Based on this information, we decided that Medicare rules for coverage of the billed testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the panel testing provided on 
March 1, 2023, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81403, 
81404, 81405, 81406, 81407, 81408, and 81479.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walking boot identified with code L4361 for date of 
service December 21, 2022. 
 
You asked the Plan to pay for the walking boot. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the code was not billed with the required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that claim lines billed with codes without a KX, GA 
or GZ modifier will be rejected as missing information. 
 We looked at the file and Medicare rules. Review of the file shows that this item was not billed with a required 
modifier. Without a required modifier billed, this code cannot be paid as billed. Based on this information, we 
decided that Medicare rules for coverage of the walking boot have not been met. Therefore, we decided that the 
Plan does not have to pay for the walking boot identified with code L4361 for date of service December 21, 
2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing provided on August 18, 2022. 
 
You asked the Plan to pay for the testing services. You say that the lab services were previously paid. The Plan 
denied your request. The Plan says that an appropriate diagnosis code was not billed. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
We looked at the file and the rules. The lab testing was performed by a par provider. The file does not show 
that the Plan provided notice that the lab testing would not be covered. Under Medicare rules, this means the 
testing services is considered approved by the Plan. You cannot be held responsible for billing errors made by a 
par provider. Therefore, we decided that the Plan has to pay for the lab testing provided on August 18, 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 pay for second stage implant surgery (D6011), a custom fabricated 
abutment (D6057), and an abutment supported crown (D6058) for tooth #27 provided on May 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that the Plan should pay for this. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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 the requested item or service was exhausted on date of service May 5, 2023, with the 
approval of D6011, D6057, and D6058 for tooth #23 and #25. Therefore, we decided that the Plan does not have to pay for second stage implant surgery (D6011), a custom fabricated abutment (D6057), and an abutment 
supported crown (D6058) for tooth #27 provided on May 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 17, 2023, billed with 
procedure codes 95937-26, 95940-XP and G0453-59. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 95937-26, 95940-XP and G0453-59 is continuous 
intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, 
(attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure), 
continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring 
personal attendance, each 15 minutes (List separately in addition to code for primary procedure), and neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. 
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found 95940 is not supported as procedure 
report does not support units billed.  Procedure report does not include sufficient documentation to support 
rational of billing both procedure codes, and therefore G0453 cannot be verified. Procedure report does not 
include documentation of neuromuscular junction testing. It is not appropriate to bill separately for train-of-
four (TOF) monitoring. CPT code 95937 is not appropriate for this procedure, nor may TOF monitoring be 
billed with an unlisted code. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on May 17, 2023, billed with procedure codes 
95937-26, 95940-XP and G0453-59.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 31, 2022, 
to January 11, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services and diagnoses were reported appropriately. The Plan denied your request. The Plan says the diagnosis 
of sepsis, unspecified organism (A41.9) is not supported in the records provided; therefore, the DRG is 
changed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with sepsis, unspecified organism (A41.9). 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 inpatient hospital services at the DRG originally billed. 
Our reviewer says that this diagnosis is not supported in the records provided. Our physician reviewer found 
the enrollee presented with worsening shortness of breath. She was assessed to have interstitial lung disease 
and treated for possible pneumonia. There is no evidence that the enrollee had sepsis (i.e., hypotension, 
hypoperfusion, organ failure). As such, the billing of A41.9 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on December 31, 2022, to January 11, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM) 
system. 
 
You asked the Plan to pre-approve the Dexcom G7. You say that this is a medical necessity.  The Plan denied 
your request. The Plan says a continuous glucose monitor is covered under Medicare only if a member with 
diabetes is on insulin or has documentation of very low blood sugars that has occurred several times.  
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs 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 pre-approve the Dexcom G7. Our reviewer says that 
this item is not medically necessary. Our physician reviewer found coverage criteria for CGM require insulin 
use or low blood glucose sugar. The enrollee is not on medications that typically cause low blood glucose sugar 
and we are not told of low blood glucose. The enrollee is not on insulin and although the prescribed Dexcom 
G7 may help, coverage criteria are not met. 
 
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 Dexcom G7 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM) system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 2, 2023.  
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable.  
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, biopsy, and lab work provided on May 10, 
2023, by out-of-network (OON) providers.  
 
You asked the Plan to pay for the visit and lab work. You say that you were not aware that you needed a 
referral from your primary care provider. The Plan denied your request. The Plan says that their original 
decision to deny payment was correct. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit, biopsy, and lab work provided on 
May 10, 2023, by out-of-network (OON) providers.