Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the oral appliance (D9999) provided February 20, 2023. 
 
You asked the Plan to pay for  the oral appliance. You say that this was not a dental procedure, but a medical 
procedure for sleep apnea and should be covered as such. The Plan denied your request. The Plan says there is 
a more appropriate code for the service. The enrollee does not have enhanced dental benefits for the requested 
dental code. The Plan states if a correct code were submitted (for example, E0486), the service would be 
covered under the medical benefit. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the oral appliance have not been met. This decision is purely based 
upon incorrect coding. There is a more appropriate code for the service. Furthermore, you do not have 
enhanced dental benefits for the requested dental code. The Plan states if a correct code were submitted (for 
example, E0486), the service would be covered under the medical benefit. Therefore, we decided that the Plan 
does not have to pay for  the oral appliance (D9999) provided February 20, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99285 and 93010 for date of service 
November 10, 2022. 
 
You asked the Plan to pay for procedure codes 99285 and 93010. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 99285 and 93010 are not supported in the medical record. Specifically, no medical 
records were provided. Without medical records it could not be determined if services rendered were medically 
necessary/ met the proper coding guidelines. The codes are not payable as billed. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99285 and 93010 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99285 and 93010 for date of service 
November 10, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Breast Cancer Index testing (81518) billed for date of service April 11, 
2023. 
 
You asked the Plan to pay for Breast Cancer Index testing. You say that this test was necessary and was 
reported appropriately. The Plan denied your request. The Plan says that this claim was submitted with an 
incorrect date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, laboratory services should be reported 
with the date of specimen collection as the date of service. However, there are exceptions to this rule.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Breast Cancer Index testing have been met. Specifically, the records indicate that the specimen in 
this case was breast tissue which would have been collected during a medically necessary hospital encounter. 
The test was performed after discharge. This means that the appropriate date of service to report on this claim 
would have been the date the test was reported: April 11, 2023. Therefore, we decided that the Plan has to pay 
for Breast Cancer Index testing (81518) billed for date of service April 11, 2023.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0453 billed for date of service October 31, 
2022. 
 You asked the Plan to pay for procedure code G0453. The Plan denied your request. The Plan says payment for 
code G0453 is bundled into payment for code 95955. 
 
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 G0453 
is a column II code to column I code 95955. 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 G0453 billed for date of service October 31, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Train of Four (TO4) testing (95999 x2 units) provided 
March 30, 2022.  
You asked the Plan to pay for procedure code 95999. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 95999 is 1. The MAI value for this code is 3. You billed 2 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. Train-of-four monitoring is considered 
integral to intraoperative neuromonitoring and/or administration of anesthesia and, therefore, is not separately 
reportable. Based on this information, we decided that Medicare rules for coverage of procedure code 95999 
have not been met. Therefore, we decided that the Plan does not have to pay for the Train of Four (TO4) testing 
(95999 x2 units) provided March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 provided on October 25, 2022. 
 
You asked the Plan to pay for procedure code 99223. You say that the medical records support the billing of 
code 99223. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99223. 
 
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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
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 99223. Our reviewer says that the medical 
records do not support the billing of code 99223. Our reviewer found the documentation supports a 
comprehensive exam, but not a comprehensive history or medical decision making of high complexity.  
 
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 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 provided on October 25, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90853 billed for date of service March 2, 
2023.  
 You asked the Plan to pay for procedure code 90853. 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 90853 is 1. The MAI value for this code is 3. You billed 6 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 code 90853 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 90853 billed for date of service March 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99232) provided on March 16, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for the requested services (99232) is included in the global 
surgery payment for the procedure (32663) provided on March 15, 2023, which has a 90-day global period. 
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 (99232) provided on March 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies billed with codes A4358, A5114, A4340, 
A4331, and A4333 for March 15, 2023, to April 19, 2023. 
 
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 services are 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 codes A4331 and A4333 have a Status Indicator of X on the Physician Fee Schedule. 
This means that procedure codes A4331 and A4333 are statutorily excluded from Medicare payment. 
Procedure codes A4358, A5114, and A4340 have a Status Indicator of P on the Physician Fee Schedule. This 
means that procedure codes A4358, A5114, and A4340 have excluded/bundled Medicare payment. 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 pay for the supplies billed with codes A4358, A5114, A4340, A4331, 
and A4333 for March 15, 2023, to April 19, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 23, 2023, to 
March 24, 2023. 
 You asked the Plan to pay for the home health services. You say that you believe the NOA was submitted 
timely. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim 
was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 24, 2023. The NOA was not received by the Plan until June 30, 
2023. Although you claim that you sent the NOA in a timely manner, the proof that you offered does not show 
to whom the NOA was sent, nor does it show that it was received by the Plan. As more than 30 days passed 
between the timely filing date and the NOA receipt, no payment can be made on this claim. Therefore, we 
decided that the Plan does not have to pay for home health services provided from February 23, 2023, to March 
24, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (78815) provided on April 14, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says records were not 
submitted by the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the services have been met. The case 
file does not contain medical records from the non-contract provider. Therefore, we decided that the Plan does 
not have to pay for the services (78815) provided on April 14, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75710 and 37253 (5 units) billed for date of 
service October 11, 2022. 
 
You asked the Plan to pay for procedure codes 75710 and 37253. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says these services are 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 75710 is angiography, extremity, unilateral, radiological supervision and interpretation. The CPT Code Manual definition of code 37253 is intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure).
 
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 codes 75710 and 37253. Our reviewer says that 
these codes are not supported in the documentation provided. Our reviewer found Code 37253 is for 
intravascular ultrasound for each additional vessel that is not a heart vessel (noncoronary) after the first and 
includes radiological supervision and interpretation. This procedure was not found in operative report, and 
therefore cannot be verified. Code 75710 is for contrast injected through a catheter into an artery of the upper 
or lower extremity (or aorta) to evaluate the arteries of one or both lower or upper extremities. This procedure 
was not found documented in operative report and therefore cannot be verified. 
 
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 codes 75710 and 37253 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 75710 and 37253 (5 units) billed for date of service 
October 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311) for a power wheelchair. 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection. You say 
that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says 
the requested items 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 an expandable controller with harness 
and electronic connection. Our reviewer says that the requested items are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that the enrollee has sufficient strength and function 
in upper extremities to manage standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller with harness and electronic connection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with 
harness (E2313) and electronic connection (E2311) for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker (E0143) provided on April 7, 2023. 
 
You asked the Plan to pay for the walker. You say that this service was medically necessary. The Plan denied 
your request. The Plan says the claim is missing a required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier KX is required to show that all of the 
medical criteria for E0143 have been met.  
 
We looked at the file and Medicare rules. The code was not billed with modifier KX as required. Based on this 
information, we decided that Medicare rules for coverage of the walker have not been met. Therefore, we 
decided that the Plan does not have to pay for a walker (E0143) provided on April 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on May 4, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration stating this is an 
urgent care visit. The Plan denied your request. The Plan says this provider is not a network provider with 
the Plan. They have also determined that these services are not urgent or emergent, nor were they approved in 
advance. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on May 4, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64448 billed for March 15, 2023. 
 
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 procedure code 64448 is not supported. 
 
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 64448 is injection(s), anesthetic agent(s) and/or steroid; 
femoral nerve, continuous infusion by catheter (including catheter placement), including imaging guidance, 
when performed.  

We find that CPT code 64448 is not supported in the medical record. Specifically, there is no documentation of 
injections, anesthetic agents, and/or steroid of the femoral nerve, with continuous infusion by catheter, with 
imaging guidance. 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 pay for procedure code 64448 billed 
for March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home evaluation visit (99342) provided on April 03, 
2023. 
 
You asked the Plan to pay for the home evaluation visit (99342). You say that the service should be covered. 
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 evaluation 
visit (99342) provided on April 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921). 
 
You asked the Plan to pre-approve D4921. You say that this is not a covered benefit. The Plan denied your 
request. The Plan says this dental procedure 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 pre-approve 
gingival irrigation (D4921).