Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on August 24, 
2023. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you received the standard 
procedure for having nodules or growth and are inquiring about the $0 payment when this is a covered 
procedure. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $150 copayment for the ultrasound. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. However, since the allowed amount is less than the standard 
copayment, you only owe $108.63. Therefore, we decided that the Plan does not have to waive the copayment 
for the ultrasound provided on August 24, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six home skilled nursing visits. 
 
You asked the Plan to pre-approve home health services. You say that the requested skilled nursing home 
health services are medically necessary for your condition. You also say that you have declined dramatically in 
your mobility and your left arm has lost a lot of strength. The Plan denied your request. The Plan says the 
services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation does not reveal evidence of new enteral feedings, complex wound care, or other ongoing skilled 
professional nursing needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve six home skilled nursing visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an i-Factor allograft. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee was being treated for 
spondylosis without myelopathy or radiculopathy. He presented with low back pain that radiates to the lower 
extremity to the calf. There are no noted examination findings. There is limited published, large-scale, long-term peer-reviewed literature that shows the i-Factor allograft to be an effective and/or safe treatment for the 
noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested i-Factor allograft 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an i-Factor allograft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a third level facet joint injection provided on  
October 16, 2023. 
 
You asked the Plan to pay for the third level facet joint injection. You say that a third level facet joint injection 
was medically necessary. The Plan denied your request. The Plan says one to two levels, either unilateral or 
bilateral, are allowed per session per spine region. The provider did not provide evidence of unique 
circumstances for a third level with sufficient documentation of medical necessity.  
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered under unique circumstances and with sufficient documentation of medical necessity on appeal. 
 
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 third level facet joint injection. Our 
reviewer says that the requested third level facet joint injection is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that there is no documentation explaining extraordinary 
circumstances to exceed the Medicare LCD limit of two levels either unilateral or bilateral. Therefore, the 
request is deemed not medically reasonable and 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 third level facet joint injection have not been met. Therefore, we decided 
that the Plan does not have to pay for a third level facet joint injection provided on October 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services rendered from October 22, 2022, to December 2, 2022.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says several items and services initially denied due to not having an itemized bill have now been identified as routine items and services.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

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 after a review of the denied services, the claims were appropriately denied. The items describe, personnel, disposable and routine services, which are included in the "room and board" charges. 

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 inpatient hospital services rendered from October 22, 2022, to December 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the office visit (99215), provided on 
October 5, 2023. 
 
You asked the Plan to waive the coinsurance for the office visit. You say that the cost share is wrong. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 47% 
coinsurance for Physician/Practitioner services, including doctor's office visits.   

You have been asked to pay a 47% coinsurance for the office visit. This item/service falls within the 
Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for the office visit (99215), provided on October 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous moderate (conscious) sedation/analgesia-first 
15 minutes (D9239) and the intravenous moderate (conscious) sedation/analgesia-each subsequent 15 minute 
increment (D9243) provided on June 27, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided are not covered under 
the supplemental dental policy.  
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intravenous 
moderate (conscious) sedation/analgesia-first 15 minutes (D9239) and the intravenous moderate (conscious) 
sedation/analgesia-each subsequent 15 minute increment (D9243) provided on June 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87634, and 87798 billed for date of 
service September 12, 2023.  
 
You asked the Plan to pay for procedure codes 87481, 87634, and 87798. You say that you would like the Plan 
to reconsider their denial of payment. 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 87481 is 5. The MAI value for this code is 3. You billed 7 units of this 
code, exceeding the MUE. The MUE for CPT code 87634 is 1. The MAI value for this code is 3. You billed 2 
units of this code, exceeding the MUE. The MUE for CPT code 87798 is 13. The MAI value for this code is 3. 
You billed 14 units of this code, exceeding the MUE. You did not provide all the required evidence showing 
that the excess units were actually provided, were correctly coded, and were medically necessary. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 87481, 87634, and 87798 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 87634, and 
87798 billed for date of service September 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service September 
15, 2023. 
 
You asked the Plan to pay for the billed code. You say that the test was needed to monitor possible opioid 
abuse. The Plan denied your request. The Plan says the code is not separately reportable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. We find that the testing described by code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the billed code have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 83789 billed for date of service September 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77003 and 69990 billed for date of service 
August 17, 2023.  
 
You asked the Plan to pay for 77003 and 69990. You say that 77003 and 69990 should be paid as billed 
because they are supported in the medical records. The Plan denied your request. The Plan says 77003 is 
denied because it is an add-on code and was not billed with an appropriate primary procedure. 69990 is denied 
because payment for this service is bundled into payment for code 63047. 
 
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 77003 is an add-on code and has not been billed with an appropriate 
primary procedure code. As such, the denial of 77003 is appropriate. Regarding code 69990, we have 
confirmed that code 69990 is a column two code to column one code 63047 with a modifier indicator of 0. The 
column two code is therefore not payable. As such, the denial of 69990 is appropriate. 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 codes 77003 and 69990 billed for date of service August 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional payment for the periodontal scaling and root 
planing-four or more teeth of the lower left quadrant (D4341) provided on August 16, 2023. 
 
You asked the Plan to pay for this service. 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 service 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 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 service provided was previously exhausted. Specifically, the Plans contract states 
that the annual maximum dental benefit is $2,000. The Plan previously issued payments in the total amount of  
$2,000 ($1,423.60 + $326.81 + $249.59) for dental services provided in the 2023 calendar year. Therefore, you 
have exhausted the allowable benefit for the service provided in this case. Therefore, we decided that the Plan 
does not have to issue additional payment for the periodontal scaling and root planing-four or more teeth of the 
lower left quadrant (D4341) provided on August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periapical radiographic image (D0220) provided on 
September 8, 2023, to September 9, 2023. 
 
You asked the Plan to pay for D0220. You say that you believe the Plan should pay for this. The Plan denied 
your request. The Plan says the denied dental service 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 
periapical radiographic image (D0220) provided on September 8, 2023, to September 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist office visits provided from 
April 28, 2022, to May 26, 2022. 
 
You asked the Plan to waive the copayments for the specialist office visits. You say that these services should 
be fully covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $25 copayment for each specialist physician visit. 
 
The enrollee has been asked to pay a $25 copayment for each specialist office visit provided on April 28, 2022, 
and May 26, 2022. These items/services fall within the physician/practitioner services, including doctor's office 
visits benefit category. This means that the enrollee has been asked to pay the correct amount based on the 
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in 
the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the specialist office 
visits provided from April 28, 2022, to May 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty. 
 
You asked the Plan to pre-approve a kyphoplasty. You say that the enrollee has difficulty ambulating and doing 
activities of daily living. The Plan denied your request. The Plan says the medical criteria for this procedure 
have not been met. 
 
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 kyphoplasty. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the magnetic resonance imaging (MRI) study of the lumbar spine showed a mild, acute 
compression fracture involving the superior endplate of L3 with less than 25% vertebral body height loss, mild 
retropulsion of the posterior superior endplate with spinal canal stenosis. However, on both imaging studies, 
there is corroboration of retropulsion and other plausible causes of pain. Additionally, there is no detailed 
documentation supporting the compression fracture is non-healing or progressive. 
 
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.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the all-lower extremity prostheses, flex-walk system or equal 
(L1851). 
 
You asked the Plan to pre-approve the flex-walk system. You say that the proposed microprocessor knee and 
flex-foot are the safest option to allow the enrollee to complete activities of daily living. The Plan denied your 
request. The Plan says that the request for a K3 microprocessor knee exceeds enrollee's need and cannot be 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 flex-walk system. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is noted to walk around their home and outdoors on a daily basis. The 
prosthetist noted the enrollee is motivated and is a K3 level ambulator. The enrollee takes care of their home 
and does yard work. Activities include cycling, hiking, fishing, shopping, and being active in the community. 
The physician documentation states the enrollee has the potential to use a prosthesis to aid in all activities of 
daily living's independently and ambulate in the community with the potential to traverse over small 
environmental barriers with an assistance device consistent with a K2 ambulatory level on July 25, 2023. Notes 
from November 16, 2023, from the physician states the enrollee is a K3 level ambulator. The physician and 
prosthetist notes corroborate enrollees K3 functional level. Based off the provided documentation, the criteria 
is met and the prosthetic foot is medically 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 flex-walk system have been met. Therefore, we decided that the Plan has to 
pre-approve the all-lower extremity prostheses, flex-walk system or equal (L1851).  
 
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 95907 billed for date of service August 19, 
2020.  
 
You asked the Plan to pay for procedure code 95907. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 95907 is bundled into payment for code 95868.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.

In this case, we have confirmed that code 95907 is a column two code to column one code 95868 with a modifier indicator of 0. The column two code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 95907 billed for date of service August 19, 2020.