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

 
We decided that the Plan does not have to pay for the home visit evaluation provided on January 24, 2023. 
 
You asked the Plan to pay for the home visit evaluation. You say that you are requesting reconsideration of 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 the home visit 
evaluation provided on January 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75710-XU provided on January 18, 2023. 
 
You asked the Plan to pay for procedure code 75710-XU. You say that the medical records support the use of 
modifier XU with procedure code 75710 to represent that it is distinct from procedure code 37225 because it 
does not overlap usual components.  The Plan denied your request. The Plan says the medical records do not 
support the use of modifier XU with procedure code 75710 to represent that it is distinct from procedure code 
37225 because it does not overlap usual components.  
 
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 75710 is a column II code to column I code 37225; however, 75710 
was billed with a modifier.  
 
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 procedure code 75710-XU. Our reviewer says that the 
medical records do not support the use of modifier XU with procedure code 75710 to represent that it is distinct 
from procedure code 37225 because it does not overlap usual components.  Our reviewer found the medical 
records provided does include documentation of an angiography for a unilateral extremity with radiological 
supervision and interpretation performed on January 18, 2023. However, the medical records submitted also 
documented that procedure code 37225 RT, an open or percutaneous endovascular revascularization of a 
unilateral femoral or popliteal artery(s), with atherectomy, including angioplasty within the same vessel, when 
performed was also performed on January 18, 2023. Procedure code 75710 has a bundled relationship with 
procedure code 37225. The medical records do not include sufficient documentation to validate that 75710 was 
performed as a distinct procedure that was independent from the primary procedure, therefore the use of an XU 
modifier is not appropriate, and no additional reimbursement is allowed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 75710-XU have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 75710-XU provided on January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instructions (D1330) provided on February 
27, 2023. 
 
You asked the Plan to pay for the prophylaxis - adult (D1110), topical application of fluoride varnish (D1206), 
and oral hygiene instructions (D1330). You say that you do not agree with the denial. The Plan denied your 
request. The Plan says the oral hygiene instructions are not a covered service under your 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the oral hygiene instructions are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral 
hygiene instructions (D1330) provided on February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 2, 2022, billed 
with codes 81292, 81295, 81298, 81317, 81351, 81406, 81407, and 81408. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. 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 genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 2, 2022, billed with codes 81292, 81295, 81298, 81317, 81351, 81406, 81407, and 81408.
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 27, 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 billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 We find that CPT code 99232 is not separately payable as billed. Review of the file shows that surgery 
procedure 43840 was provided on February 8, 2023. Code 43840 has a global surgery value of 90 days. Code 
99232 was billed within the global surgery period of procedure 43840 without an appropriate modifier. This 
means code 99232 is not separately payable as billed. 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 27, 2023.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99283 for date of service December 20, 2022. 
 
You asked the Plan to pay for procedure code 99283. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the Plan states that the diagnosis is inconsistent 
with the procedure provided. The Medicare rules provided by the Plan to support this denial do not state the 
diagnosis code billed (Z00.00- encounter for general adult medical examination without abnormal findings) is 
not appropriate for the services rendered. The rules state that Z codes are for use in any healthcare setting. No 
other denial rationale was provided by the Plan. The Plan did not substantiate their denial. Therefore, we 
decided that the Plan has to pay for procedure code 99283 for date of service December 20, 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 core buildup, including any pins when required (D2950) 
provided on February 27, 2023. 
 
You asked the Plan to pay for the core buildup, including any pins when required. You say that the cost of the 
crown is covered by your benefit plan but the core buildup that the crown will rest on is not covered. You ask, 
how does this make sense as the doctor cannot place the crown without the base buildup. The Plan denied your 
request. The Plan says the D2950 service is not covered under your plan 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 core buildup, including any pins 
when required is not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for core buildup, including any pins when required (D2950) provided on February 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality tests (D0460), and pulpal debridement 
(D3221) provided from June 30, 2022, to October 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you got approval for these out-of-network 
procedures. The Plan denied your request. The Plan says these services are not covered under the Plan's 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pulp 
vitality tests (D0460), and pulpal debridement (D3221) provided from June 30, 2022, to October 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150), bitewing x-rays-four 
radiographic images (D0274), and the dental cleaning (D1110) provided on February 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
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 Plan's 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 services provided has already been exhausted. Specifically, the Plan's contract states 
that a comprehensive oral exam is covered once every 36 months. You previously received this service on 
February 9, 2021, less than 36 months prior, which was paid for by the Plan. The Plan's contract states that  
bitewing x-rays are covered once every 12 months. You previously received this service on February 9, 2022, 
less than 12 months prior, which was paid for by the Plan. Additionally, the Plan's contract states that two 
dental cleanings are covered every 12 months. You previously received these services on February 9, 2022 and 
August 10, 2022, less than 12 months prior, which were paid for by the Plan. Therefore, you have exhausted 
the allowable benefit for the dental services provided in this case. Therefore, we decided that the Plan does not 
have to pay for the comprehensive oral exam (D0150), bitewing x-rays-four radiographic images (D0274), and 
the dental cleaning (D1110) provided on February 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty at L4 (22514). 
 
You asked the Plan to pre-approve a kyphoplasty. You say that this procedure should be covered. The Plan 
denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a kyphoplasty is covered when all the criteria listed in 
the Medicare rules section are met. 
 
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 kyphoplasty. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that the MRI performed on June 26, 2023, 
showed an acute to subacute L4 superior endplate compression fracture and approximately 30% vertebral 
height loss.  However, it is not clearly documented that the enrollee has worsening pain or a progression of 
vertebral body height loss. The x-ray performed on June 23, 2023, was negative for any compression fractures. 
Kyphotic deformity is not documented. The enrollee is not clearly documented to have severe impacts on her 
daily functioning due to the vertebral compression fracture. Moreover, the MRI also demonstrated other 
plausible causes for her noted pain. The current back pain cannot conclusively be noted to be from the vertebral 
compression fracture. This is an absolute contraindication for the procedure.  
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty at L4 (22514).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22514).  

You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary when specific criteria are met. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the lumbar magnetic resonance imaging 
(MRI) demonstrated an L2 superior endplate burst fracture. However, the age of the fracture is not clearly 
noted, as the MRI stated "likely" subacute. Additionally, the MRI noted mild vertebral body height loss 
without clearly indicating a greater than 25% vertebral body height reduction or any progression of body height 
loss. There is no kyphotic deformity noted. You do not present with worsening pain (and only notes that there 
is significant pain with no clear pain scale rating.) Therefore, you do not meet the coverage criteria detailed in 
the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22514).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services are necessary for the enrollee to have 
their complex medical conditions managed, for the enrollee to regain maximum function, and to prevent further 
loss of function. You say this cannot be done at the skilled nursing level of care. The Plan denied your request. 
The Plan says the IRF services 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the enrollee may have a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (87481) and 
infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics 
(87900) provided November 8, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that this test was ordered based upon the treating 
physicians clinical training and medical necessity. The Plan denied your request. The Plan says the procedure 
was not appropriate for the clinical situation.  
 
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 laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee had complaints of lower abdominal pain and 
straining with urination. There was no specific clinical rational for the obtained infectious agent detection by 
nucleic acid (deoxyribonucleic acid (DNA) or ribonucleic acid (RNA)); Candida species, amplified probe 
technique (87481) and infectious agent drug susceptibility phenotype prediction using regularly updated 
genotypic bioinformatics (87900). Urinalysis with urine culture is the standard of care for a urinary tract 
infection. The review has determined that the procedure was not appropriate for the clinical situation.  
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the infectious agent detection by nucleic acid (87481) and infectious agent drug 
susceptibility phenotype prediction using regularly updated genotypic bioinformatics (87900) provided 
November 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675), provided on 
December 23, 2022.. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item should be covered. The 
Plan denied your request. The Plan says a pneumatic compression device is not covered for preventative 
services during or after surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675), provided on December 23, 2022..
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar decompression surgery. 
 
You asked the Plan to pre-approve the surgical service. You say that you have tried physical therapy, 
acupuncture, and custom inserts. You say that none of these have helped with your pain. You say that your 
quality of life has been effected. You also say that you would like to have this surgery done sooner than later 
due to the associated health risks. The Plan denied your request. The Plan says the documentation does not 
show that you have significant nerve pinching in your spine. The Plan also says that the requested procedure 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 surgical service. Our reviewer says 
that the requested lumbar decompression surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation have evidence of severe spinal stenosis and 
neve root compression. Therefore, the reviewer found that the requested lumbar decompression surgery is not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgical service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve lumbar decompression surgery.