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

 
We decided that the Plan does not have to pay for procedure code P9604 billed for date of service July 12, 
2022. 
 
You asked the Plan to pay for procedure code P9604. You say that this service was reported appropriately. The 
Plan denied your request. The Plan says this service is not supported in the medical record. 
 
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 P9604 is travel allowance one way in connection with medically necessary laboratory specimen collection 
drawn from home bound or nursing home bound patient; prorated trip charge. 
 
We find that CPT code P9604 is not supported in the medical record. Specifically, there is no documentation of 
any travel relating to these services. Based on this information, we decided that Medicare rules for coverage of procedure code P9604 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code P9604 billed for date of service July 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 billed for date of service October 19, 
2022. 
 
You asked the Plan to pay for procedure code 87481. The Plan denied your request. The Plan says payment for 
code 87481 is bundled into payment for code 87801. 
 
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 87481 
is a column II code to column I code 87801. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 87481 billed for date of service October 19, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service August 29, 
2022. 
 
You asked the Plan to pay for procedure code 93010. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 93010 is bundled into payment for code 
36556. 
 
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 93010 
is a column II code to column I code 36556. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93010 billed for date of service August 29, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service October 9, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service October 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99222) provided on February 22, 2023. 
 
You asked the Plan to pay for the services. 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 an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 indicates 
that the two conditions cannot occur together.  
 
We looked at the file and Medicare rules. In this case, the claim was billed with diagnosis codes R11.2 and 
K92.0. Diagnosis code R11.2 has an Excludes1 note and cannot be billed with diagnosis code K92.0. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (99222) provided on February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain - minor 
procedure (D9110), intraoral - periapical first radiographic image (D0220), and each additional radiographic 
image (D0230) provided on January 17, 2023 to March 27, 2023. 
 
You asked the Plan to pay for the extraction, palliative treatment, intraoral - periapical first radiographic image 
and each additional radiographic image.. You say that the dentist informed you that the plan is not paying for 
the services. You also say that you would like the bill paid because you are on a fixed income. The Plan denied 
your request. The Plan says your benefit for the requested services 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 intraoral x-rays, D0220 and D0230 were exhausted on date of service February 20, 
2023.  
 
The record for the palliative treatment D9110 was exhausted on dates of service February 20, 2022, and March 
22, 2023. Therefore, we decided that the Plan does not have to pay for the palliative (emergency) treatment of 
dental pain - minor procedure (D9110), intraoral - periapical first radiographic image (D0220), and each 
additional radiographic image (D0230) provided on January 17, 2023 to March 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 3, 2022, billed with 
codes 81227, 81230, 81231, 81232, 81355, 0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that the treatment sought was medically 
necessary. 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. The panel testing 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 August 
3, 2022, billed with codes 81227, 81230, 81231, 81232, 81355, 0031U, 0032U, and 0033U.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that when three or more 
power seating functions/actuators/motors are provided, one unit of E2311, one unit of E2377, and one unit of 
E2313 are allowed. You also say that you would like this to be reviewed for approval of the necessary 
electronics for the power wheelchair.  The Plan denied your request. The Plan says  although there are three 
requested power options (tilt, recline and elevating leg rests), there is not a medical need to control these power 
options through the joystick.  
 
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 durable medical equipment (DME). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has adequate strength to manage standard power drives. 
The expandable controller is not medically necessary to meet the enrollee's 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 the durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97014 billed for date of service January 10, 
2023. 
 
You asked the Plan to pay for procedure code 97014. You say that the claim should be paid. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97014 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 97014 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 97014 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 97014 billed for date of service January 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three additional office visits and epidural steroid 
injections.  
 
You asked the Plan to pre-approve three additional office visits and epidural steroid injections. You say that the 
records provided support the need for the services in dispute.  The Plan denied your request. The Plan says the 
repeat epidural steroid injection interventions are not considered reasonable and medically necessary because there is not yet evidence of at least 50% sustained improvement in pain relief and/or improvement in function 
measured from baseline using the same scale for at least three months.  
 
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 three additional office visits and 
epidural steroid injections. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic back pain after a 
laminectomy. He has a Spinal Cord Stimulator (SCS) in place. There is no documentation of ongoing 
conservative therapy. The rationale for epidural steroid injections after SCS placement is not stated. The 
enrollee needs re-programming trials.  An epidural steroid injection in the presence of an SCS is not evidence 
based and is 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 three additional office visits and epidural steroid injections have not been met. 
Therefore, we decided that the Plan does not have to pre-approve three additional office visits and epidural 
steroid injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connector (E2310). 
 
You asked the Plan to pre-approve an electronic connector. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says the requested item 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 an electronic connector. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does have use of the upper extremities and can operate and control 
the power options using the switches that are included in the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connector have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connector (E2310).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 home physical therapy visits. You asked the Plan to pre-approve home health 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. 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 that the 
provided records document the enrollee was ambulating up to 220 to 300 feet with contact guard assistance and 
was independent with transfers as of July 14, 2023. The records at that time also report the enrollee was 
challenging to work with, was refusing some treatments, and was requesting to discontinue home health 
services. No medical notes from the enrollee's treating physician are provided documenting an order or need for 
additional skilled physical therapy services. After the therapy treatments already approved, the records do not 
support that the complexity of the enrollees conditions are such that the skills of a professional therapist are 
required to achieve further improvement in the enrollees symptoms or functional status. Further utilization of 
the home exercise program appears appropriate at this point. 
 
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 10 home physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93042 and 99292 billed for date of service 
December 27, 2022. 
 
You asked the Plan to pay for procedure codes 93042 and 99292. You say that medical records were provided. 
The Plan denied your request. The Plan says payment for codes 93042 and 99292 are bundled into payment for 
code 36556. 
 
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 codes 93042 and 99292 are column II codes to column I code 36556. 
Codes 93042 and 99292 have not been billed with an appropriate modifier to bypass the edit. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 93042 and 99292 billed for date of service December 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve exploration of the spinal fusion (22830). 
 
You asked the Plan to pre-approve exploration of the spinal fusion. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria 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 exploration of the spinal fusion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the diagnosis of nonunion has not been established. Also, exploration code 
cannot be billed at same level as a fusion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of exploration of the spinal fusion have not been met. Therefore, we decided that 
the Plan does not have to pre-approve exploration of the spinal fusion (22830).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on March 6, 2023, billed with 
code A4556. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this service is 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided have not been met. Procedure code A4556 has a status indicator of P 
and is not separately payable. Therefore, we decided that the Plan does not have to pay for imaging services 
provided on March 6, 2023, billed with code A4556.
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 January 7, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the claim should be processed at the in-
network benefit. 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 January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from December 7, 2022, to  
December 25, 2022. 
 
You asked the Plan to pay for the SNF care. You say that the SNF was medically necessary. The Plan denied 
your request. The Plan says the enrollee has exhausted the SNF benefit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
 The file shows that the enrollee received 100 days of SNF care during the benefit period from April 15, 2022 
and December 6, 2022. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for SNF care provided from December 7, 2022, to December 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87641 and 87801 billed for date of service 
January 21, 2023. 
 
You asked the Plan to pay for procedure codes 87641 and 87801. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says payment for code 87641 is bundled into payment 
for code 87801. Payment for code 87801 is bundled into payment for code 87631. 
 
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 87641 
is a column II code to column I code 87801. Furthermore, code 87801 is a column II code to column I code 
87631. These claim lines have not been billed with appropriate modifiers to bypass the edits. 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 87641 and 87801 billed for date of service January 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits (99203, 99212), massage therapy (97124), 
infrared therapy (97026), manual therapy (97140), neuromuscular reeducation (97112), and the mechanical 
traction therapy (97012) provided from February 8, 2023, through March 3, 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 these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
  
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visits (99203, 99212), massage therapy (97124), infrared 
therapy (97026), manual therapy (97140), neuromuscular reeducation (97112), and the mechanical traction 
therapy (97012) provided from February 8, 2023, through March 3, 2023.