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

 
We decided that the Plan does not have to pay for procedure code 99213 for date of service July 17, 2023. 
 
You asked the Plan to pay for procedure code 99213. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the service at issue was not billed with the required modifier to allow 
separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 36482 
provided on the same date of service. We find that the service at issue may be unrelated to the surgical 
procedure; however, the required modifier to indicate this was not used. As such, the billing rules for these 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99213 
for date of service July 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related accessories 
provided on June 22, 2023. 
 
You asked the Plan to pay for the billed services. You say that this device was provided for use during the 
patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a procedure is 
not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 
 The claim shows the items at issue were provided in an ambulatory surgical center. Although the items may be 
helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that 
the Plan does not have to pay for the pneumatic compression device and related accessories provided on June 
22, 2023.
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 the enrollee requires LTACH services to 
regain their prior level of functioning and independence. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with 
concurrently acquired computed tomography (CT) scan (78815).  
 
You asked the Plan to pre-approve the PET/CT scan. You say that the enrollee is having memory loss and you 
need to see how they can be treated. The Plan denied your request. The Plan says the criteria for coverage have 
not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET/CT scan. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the records provided for review did 
not demonstrate that the enrollee meets the criteria for both Alzheimer's disease (AD) and frontotemporal 
dementia (FTD). Therefore, this request does not meet the requirements for coverage at this time. 
 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 PET/CT scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a positron emission tomography (PET) scan with concurrently acquired computed 
tomography (CT) scan (78815).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 office visits to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the office visits. You say that the enrollee has been a patient with this doctor 
since 2021. The Plan denied your request. The Plan says there are providers in the enrollee's network who can 
provide these services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out-of-area urgent care, and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
6 office visits to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for two units of procedure code 76942 rendered on May 31, 2023.

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 CPT code 76942 is allowed for a single patient encounter regardless of the number of needle placements performed and number of localizations.

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 76492 is "Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation."

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 the medical records do not support the use of two units of CPT 76942. The ultrasound guidance was only used on the right side for the block. The documentation does not show guidance used on the left. While the guidelines do allow for the use of appropriate modifiers to be able to bill outside of the MUE but within the MAI, this documentation does not support that use in this claim.

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 two units of procedure code 76942 rendered on May 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodontal scaling and root planing (D4341) for all 
4 quadrants, the gingival irrigation (D4921) on all 4 quadrants, and to pay for the medicaments (D9630) 
provided on July 19, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you asked for a standard cleaning, and 
they told you that they were in-network. The Plan denied your request. The Plan says the proper cost share was 
applied. Also, medications are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
For 1 of the periodontal scaling and root planing (D4341) the total allowed amount was $140.89. There was a 
$100 deductible applied. Which left a balance of $40.89. The coinsurance amount was $20.45 ($40.89 balance 
x 50% coinsurance). The total allowed amount for the other 3 periodontal scaling and root planing (D4341) 
was $140.89 with a coinsurance amount for each of $70.45 ($140.89 x 50% coinsurance). The total allowed 
amount for the 4 gingival irrigation (D4921) was $9.35 with a coinsurance for each of $4.68 ($9.35 allowed x 
50% coinsurance). 
 
You have been asked to pay a $100 deductible and a 50% coinsurance for the periodontal scaling and root 
planing (D4341) on all 4 quadrants and the gingival irrigation (D4921) on all 4 quadrants. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. The medicaments are not covered 
under the Plan's dental benefit. Therefore, we decided that the Plan does not have to pay more for the 
periodontal scaling and root planing (D4341) for all 4 quadrants, the gingival irrigation (D4921) on all 4 
quadrants, and to pay for the medicaments (D9630) provided on July 19, 2023. 
 
You have the right to ask us to vacate (set aside) the dismissal action. If we determine there is good cause, 
we will vacate the dismissal and review your appeal request. Your request to vacate this dismissal must be 
received by our office within 6 months of the date of this notice. Include a copy of this notice along with any 
supporting information with your request.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 200 units of Botox (J0585) given every 84 days. 
 
You asked the Plan to pre-approve 200 units of Botox given every 84 days. The Plan denied your request. The 
Plan says the policy requirements have been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 
 
 
 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 200 units of Botox given every 84 days. 
Our reviewer says that Botox at 200 units given every 84 days is not FDA-approved for the enrollee's 
diagnosis. Our physician reviewer found the requested number of units given every 84 days is not supported by 
one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid 
Services (CMS) approved medical journal for the enrollee's diagnosis. Our reviewer found that Botox at 200 
units given every 84 days is not indicated, supported, or recommended in any of the compendia for the 
enrollee's diagnosis. Our physician reviewer also found that the documentation does not support that the 
requested drug is safe and effective and otherwise reasonable and necessary for this enrollee at a dose of 200 
units given every 84 days.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 200 units of Botox given every 84 days have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 200 units of Botox (J0585) given every 84 days.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for dates of service May 28, 
2023, to May 30, 2023. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the claim. The Plan 
denied your request. The Plan says the billed code cannot be verified. 
 
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 code 99232 is not supported in the medical record. Specifically, the records do not 
sufficiently document the dates when services were provided. 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 99232 billed for dates of service May 28, 2023, to May 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64488 billed for date of service August 1, 
2023.  
 
You asked the Plan to pay for procedure code 64488. You say that the enrollee received injections on both 
sides of the body. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 64488 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. The documentation does not show that the excess units were provided, or correctly 
coded. The CPT Code Manual definition of code 64488 is transversus abdominis plane (TAP) block 
(abdominal plane block, rectus sheath block) bilateral; by injections. The bilateral code identifies services 
provided on both sides of the body. Based on this information, we decided that Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 64488 billed 
for date of service August 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on June 8, 2023. 
 
You asked the Plan to pay for lab test. You say that you are submitting a description of the test performed. The 
Plan denied your request. The Plan says this claim was not billed with the appropriate Place of Service (POS) 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. This claim was billed with POS code 81  indicating an independent 
lab setting  however, the record does not support that the sample for this testing was taken directly in the 
independent laboratory. Based on this information, we decided that Medicare rules for coverage of lab test have 
not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on June 
8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthoses codes L1852 and L2397 billed for date of service 
May 8, 2023. 
 
You asked the Plan to pay for the billed services. You say that Medical records were provided. The Plan denied 
your request. The Plan says the requirement for approval have not been met. 
The Plan must follow Medicare rules. Medicare rules say that knee orthoses are only covered under certain 
medical indications.  
 
We find that CPT codes L1852 and L2397 are not supported in the medical record. The medical records do not 
show that the enrollees treating physician ordered the brace as part of the treatment plan. The medical records 
do not show that the enrollee was being seen for knee pain at the time of the visits provided in the records. 
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 orthoses codes L1852 and L2397 billed for 
date of service May 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311). 
 
You asked the Plan to pre-approve the connection. You say that this is medically necessary. The Plan denied 
your request. The Plan says this 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 the connection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has poor ambulation due to diabetes and arthritis. She is independent with self 
care when seated. The enrollee has adequate strength to manage standard power drives. 
 
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 connection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electronic connection (E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 81003) rendered on 
August 24, 2021. 
 
You asked the Plan to pay for the services. You say that due to the age and complexity of the patient, the 
physician determined that this testing was reasonable and necessary. 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 code 81003 is "Urinalysis, by dip stick or tablet reagent for 
bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any 
number of these constituents; automated, without microscopy." 
 
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 CPT 81003 is not supported. The 
record does not contain results showing that testing for the components of this code were performed ( bilirubin, 
glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen). The record does 
not support that CPT 81003 was performed. 
 
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 laboratory services (procedure code 81003) rendered on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 15, 2023. 
 
You asked the Plan to pay for practitioner services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for practitioner services 
provided on August 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral device (E0846), purchased on April 6, 2023. 
 
You asked the Plan to pay for the oral device. You say that the item should be covered. The Plan denied your 
request. The Plan says this item was purchased through a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the oral device (E0846), purchased on 
April 6, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi (J9173). 
 
You asked the Plan to pre-approve Imfinzi. You say that the patient meets medical necessity for Imfinzi based 
on current indications for this drug. The Plan denied your request. The Plan says the documentation does not 
support that the patient has an accepted medical indication for the use of Imfinzi. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 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 Imfinzi. Our reviewer says that Imfinzi 
is not medically reasonable and necessary. Our physician reviewer found the documentation does not support 
that the patient has an accepted medical indication for the use of Imfinzi. The use of this drug requires that the 
patient's cancer has not worsened or spread after chemotherapy and radiation. Our reviewer found that this is 
not the case. The review has determined that the requested use of Imfinzi (J9173) is not FDA-approved for the 
patients diagnosis. Our physician reviewer also found that its use is not supported by one of the major drug 
compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS) approved 
medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Imfinzi (J9173).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an audio-only telehealth visit billed with code 99214 on May 
30, 2023. 
 
You asked the Plan to pay for telehealth visit. You say that this is coded correctly and is payable. The Plan 
denied your request. The Plan says this code is not payable for an audio-only interaction. 
 
The Plan must follow Medicare rules. Medicare rules say that an audio-only interaction does not meet the 
requirements for use of code 99214 for telehealth services.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of telehealth visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
audio-only telehealth visit billed with code 99214 on May 30, 2023.