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

We decided that the Plan does not have to pay for Practitioner services provided on January 22, 2023, billed
with procedure codes Q0092 and R0070.

You asked the Plan to pay for the Practitioner services provided. You say that the claim is billed correctly and
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of codes Q0092 and R0070 is set-up portable x-ray equipment,
and transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or
location, one patient seen.

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the
Plan was correct in denying the request to pay for the Practitioner services provided. Our reviewer says that
documentation does not support the billed code. Our reviewer found that although there is a report for a chest
x-ray, there is no documentation stating it was performed with a portable x-ray machine with transportation and
setup. These codes are not substantiated by the medical record.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the Practitioner services provided have not been met. Therefore, we decided that
the Plan does not have to pay for Practitioner services provided on January 22, 2023, billed with procedure
codes Q0092 and R0070.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the leuprolide injections and the specialist 
office visits provided from June 28, 2022, to February 27, 2023. 
 
You asked the Plan to waive the cost share for the injections and the specialist office visits. You say that you 
disagree with the cost share. 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 20% 
coinsurance for Medicare Part B prescription drugs. Your contract with the Plan also clearly says that you must 
pay a $35 copay for in-network physician specialist services. 
 
You have been asked to pay 20% coinsurance for the injections. These items/services fall within the Medicare 
Part B prescription drugs benefit category.  
 
Date of Service Item Allowed Amount 20% Coinsurance 
June 28, 2022 Injection $ 674.76 $ 134.95 
October 27, 2022 Injection $665.88 $133.18 
February 27, 2023 Injection $753.32 $150.66 
 
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.  
 
You have also been asked to pay a $35 copayment for each specialist office visit provided on October 27, 2022, 
and February 27, 2023. These items/services fall within the physician/practitioner services, including doctors 
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 cost share for the leuprolide injections and 
the specialist office visits provided from June 28, 2022, to February 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) months continued use of a noninvasive 
ventilator (NIV) (E0466). 
 
You asked the Plan to pre-approve 9 months continued use of a ventilator. You say that you are requesting 
reconsideration. You have attached a compliance report and medical records to support this appeal. The Plan 
denied your request. The Plan says the request for continued use of a NIV is not medically reasonable and 
necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 9 months continued use of a ventilator. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has 
COPD and obstructive sleep apnea (OSA) and has had a home ventilator since 2017. A recent device download 
shows good compliance with use of the device. The original documentation for approval of the device is not 
provided. There are no pulmonary function tests to assess the severity of the COPD. There is no documentation 
of chronic carbon dioxide (CO2) retention with an arterial blood gas (ABG) done while stable. The records do 
not show that the enrollee has been tried on bilevel positive airway pressure (BiPAP) with average volume-
assured pressure support (AVAPS) as an outpatient.  Medicare does not cover a home ventilator when used at 
settings that can be provided with BiPAP.  The plan has approved the current device for 3 months, which 
allows time for transition to BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 9 months continued use of a ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve nine (9) months continued use of a noninvasive ventilator 
(NIV) (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 19, 2023. 
 
You asked the Plan to pay for the office visit provided on January 19, 2023. You say that after carefully 
reviewing your coverage you see that the Plan covers 20 acupuncture treatments per year on your PPO plan in 
or out of network. You say that Medicare covers 12 acupuncture treatments per year for low back pain, 
therefore you believe your acupuncture treatments for your low back pain should be covered. The Plan denied 
your request. The Plan says the only service covered by Medicare with an acupuncturist is acupuncture. 
 
The Plan contract covers up to 12 visits in 90 days for Medicare beneficiaries under the following 
circumstances: For the purpose of this benefit, chronic low back pain No more than 20 acupuncture treatments 
may be administered annually. 
 
We looked at the file and the Plans rules. The Plan acupuncture benefit only covers acupuncture, not office 
visits. Therefore, we decided that the Plan does not have to pay for the office visit provided on  
January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional levels. 
 
You asked the Plan to pre-approve the additional levels. You say that the enrollee previously had multiple 
successful radiofrequency ablation treatments. The Plan denied your request. The Plan says the requested 
radiofrequency ablations 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 the radiofrequency ablations. Our 
reviewer says that the enrollee does not meet the LCD coverage criteria. Our physician reviewer found that the 
enrollee had 80 % pain relief for 6 months after having 5 levels of radiofrequency ablations. The LCD has a 
utilization limitation of 2 levels bilaterally per session. Therefore, only 2 levels are 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 radiofrequency ablations have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the additional levels.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate (38220). 
 
You asked the Plan to pre-approve a bone marrow aspirate. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of 
spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no specific indication provided to support the request for bone marrow 
aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of bone marrow aspirate for this enrollee's medical condition. No compelling rationale is 
presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate (38220).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 22, 2023, billed with 
codes 81209, 81223, 81241, 81250, 81305, 81307, 81311, 81320 and 81334. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. 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 
January 22, 2023, billed with codes 81209, 81223, 81241, 81250, 81305, 81307, 81311, 81320 and 81334.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 22, 2022, billed with 
codes 81292 and 81294. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. 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 
July 22, 2022, billed with codes 81292 and 81294.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88291 billed for date of service July 12, 
2022. 
 
You asked the Plan to pay for procedure code 88291. You say that the clinical facts support medical necessity. 
The Plan denied your request. The Plan says payment for code 88291 is bundled into payment for code 81270. 
 
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 88291 is a column II code to column I code 81270. Code 88291 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 88291 
billed for date of service July 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Imaging services provided on February 11, 2023, billed with 
code 75716-59. 
 
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 payment for this service is included in the 
payment of another code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 75716 is a column II code to column I code 37227; however, 75716 
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 the imaging services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the work done with procedure code 
75716 is already included in procedure code 37227. Procedure code 75716 could not be verified as separately 
administered or payable. 
 
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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for Imaging services provided on February 11, 2023, billed with code 75716-59.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for dates of service from 
December 2, 2022, to December 19, 2022. 
 
You asked the Plan to pay for procedure code 97010. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says procedure code 97010 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 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for dates of service from December 2, 2022, to December 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alveoloplasty in conjunction with extractions - four 
or more teeth or tooth spaces, per quadrant (D7310), alveoloplasty in conjunction with extractions - one to 
three teeth or tooth spaces, per quadrant (D7311), and lingual frenectomy (frenulectomy) (D7962). 
 
You asked the Plan to pre-approve the alveoloplasties and lingual frenectomy (frenulectomy). You say that you 
have one broken tooth right in the middle which is the main reason you need the oral surgeon, and the rest of 
your teeth are no good. You also say that you have infections in all your other teeth, and they need to be 
extracted as soon as possible. The Plan denied your request. The Plan says these services are not covered under 
your 2023 dental plan. 
 
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 pre-approve an 
alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7310), 
alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant (D7311), and 
lingual frenectomy (frenulectomy) (D7962).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73030 billed for date of service February 24, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the medical records clearly mention the billed 
services. 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. 
 
In this case, the CPT Code Manual definition of code 73030 is radiologic examination, shoulder; complete, 
minimum of 2 views. 

We find that CPT code 73030 is not supported in the medical record. Specifically, the records do not show that 
a minimum of 2 views for the shoulder x-ray were provided. There is a more accurate code available to 
describe the services 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 
73030 billed for date of service February 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that continued use of a home ventilator is not medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has COPD and has had a home ventilator since April 2022. The records do not 
show that the enrollee has been tried on BiPAP with average volume-assured pressure support (AVAPS) as an 
outpatient. Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued use of a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit billed with code 99204 for August 23, 2022.  

You asked the Plan to pay for these services. You say that you disagree with the 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 20611 
provided on August 23, 2022. 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 the office visit billed with code 
99204 for August 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the topical application of fluoride varnish (D1206). 
 
You asked the Plan to pre-approve the dental services. You say that you are in a lot of pain and need these 
dental procedures. The Plan denied your request. The Plan says this service is not a covered benefit under your 
dental 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
topical application of fluoride varnish (D1206).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code P9603 billed for date of service November 3, 
2022. 
 
You asked the Plan to pay for procedure code P9603. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 P9603 is: Travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually travelled. 
 
We find that CPT code P9603 is not supported in the case record. Specifically, documentation of travel 
connected with laboratory specimen collection or of miles traveled has been provided. Based on this 
information, we decided that Medicare rules for coverage of procedure code P9603 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code P9603 billed for date of service 
November 3, 2022.