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

 
We decided that the Plan does not have to pay for procedure code 99336 provided on March 21, 2023. 
 
You asked the Plan to pay for procedure code 99336. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99336 is not payable in 2023. 
 
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 code 99336 is not supported in the medical record. Specifically, code 99336 is no longer a 
payable code as of January 1, 2023. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99336 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99336 provided on March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97530 and 97116 for date of service May 
15, 2023, to May 30, 2023. 
 
You asked the Plan to pay for procedure codes 97530 and 97116. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the codes at issue 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. 
 
In this case, the CPT Code Manual definition of code 97116 is therapeutic procedure, 1 or more areas, each 15 
minutes; gait training (includes stair climbing). 
 
The CPT Code Manual definition of code 97530 is therapeutic activities, direct (one-on-one) patient contact 
(use of dynamic activities to improve functional performance), each 15 minutes. 
 
We find that CPT codes 97530 and 97116 are not supported in the medical record. Specifically, the code 
definition of these codes is time-based, and the records submitted for review do not document the total time 
spent providing the services described by this code. Based on this information, we decided that Medicare rules 
for coverage of procedure codes 97530 and 97116 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 97530 and 97116 for date of service May 15, 2023, to May 30, 2023.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 97116 and 97530 provided on June 6, 2023. 
 
You asked the Plan to pay for procedure codes 97116 and 97530. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
supported as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has not provided enough evidence to support the denial of 
payment for procedure codes 97116 and 97530 based on Medicare criteria. Medicare rules say documentation 
requirements for therapy services indicates that the amount of time for each specific intervention/modality 
provided to the patient is not required to be documented in the Treatment Note. However, the total number of 
timed minutes must be documented. The medical record clearly shows the total number of timed minutes 
correctly. Therefore, we decided that the Plan has to pay for procedure codes 97116 and 97530 provided on 
June 6, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Dexcom G7 CGM. You say that the requested item is a necessity for your 
care. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are 
covered when dispensed by a pharmacy. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a continuous glucose monitor. The record indicates that the requested item would be dispensed by a 
pharmacy. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose 
monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 for date of service October 10, 2022. 
 
You asked the Plan to pay for procedure code 87481. 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. 
 
In this case, the CPT Code Manual definition of code 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. 
 
We find that CPT code 87481 is not supported in the medical record. Specifically, the code billed is incorrect 
as the amount of drug classes tested do not match the range on the billed code. Based on this information, we 
decided that Medicare rules for coverage of procedure code 87481 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 87481 for date of service October 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 26, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services/procedures (97150, 97112, 97760, 
97039, 97012, 99071, E0190, 97110, A9300, 99070) provided from June 13, 2022, to December 9, 2022. 

You asked the Plan to pay for the chiropractic services. You say that you are in constant pain and sought out 
this provider to help treat your scoliosis The Plan denied your request. The Plan says these chiropractic services 
are excluded from coverage. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic services/procedures (97150, 97112, 97760, 97039, 97012, 
99071, E0190, 97110, A9300, 99070) provided from June 13, 2022, to December 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic - porcelain/ceramic (D6245) provided on June 5, 
2023. 
 
You asked the Plan to pay for the pontic - porcelain/ceramic. You say that it is your understanding that a 
removable partial for this tooth would have been covered. You also say that you are requesting that the covered 
amount be alternately applied for the service applied to this tooth. The Plan denied your request. The Plan says 
this service is not a covered expense 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pontic - 
porcelain/ceramic (D6245) provided on June 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral complete series of radiographic images (D0210) 
and the periodontal scaling and root planing (D4341) provided on June 2, 2023, and June 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were never told that the services were not 
covered. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the intraoral complete series of radiographic images and the periodontal scaling and root planing are 
not covered by the 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 pay for the 
intraoral complete series of radiographic images (D0210) and the periodontal scaling and root planing (D4341) 
provided on June 2, 2023, and June 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) provided on June 7, 2023. 
 
You asked the Plan to pay for D1330. You say that you disagree with these charges. 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 oral 
hygiene instructions (D1330) provided on June 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious-agent testing (875002, 87633 and 87640) provided 
on February 10, 2023. 
 
You asked the Plan to pay for infectious-agent testing. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of infectious-agent 
testing have not been met. Therefore, we decided that the Plan does not have to pay for infectious-agent testing 
(875002, 87633 and 87640) provided on February 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osseous, osteoperiosteal, or cartilage graft of the 
mandible or maxilla-autogenous or nonautogenous, by report (D7950) provided on June 13, 2023. 
 
You asked the Plan to pay for this dental 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 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 service provided has been exhausted. Specifically, the Plan's contract states that one 
osseous, osteoperiosteal, or cartilage graft is covered per lifetime. On this day, you received two of these dental 
services, of which one was paid for by the Plan. Therefore, you have exhausted the allowable benefit for this 
service. Therefore, we decided that the Plan does not have to pay for the osseous, osteoperiosteal, or cartilage 
graft of the mandible or maxilla-autogenous or nonautogenous, by report (D7950) provided on June 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 for date of service October 12, 2022. 
 
You asked the Plan to pay for procedure code 87481. 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. 
 
In this case, the CPT Code Manual definition of code 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. 
 
We find that CPT code 87481 is not supported in the medical record. Specifically, the documentation shows 
that 4 drug classes were tested (Candida albicans, Candida tropicalis, Candida parapsilosis, and Candida 
glabrate). This means that five drug classes were not tested and therefore, code 87481 is not supported. Based 
on this information, we decided that Medicare rules for coverage of procedure code 87481 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 87481 for date of service October 
12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle insertion(s) without injection(s); 1 or 2 muscle(s) 
provided on October 6, 2022. 
 
You asked the Plan to pay for the needle insertion(s) without injection(s); 1 or 2 muscle(s). You say that you 
are appealing the claim payment denial. The Plan denied your request. The Plan says the requested service was 
not requested or approved on authorization 162091080. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the needle insertion was not pre-authorized prior to 
the visit and is not a covered service. Therefore, we decided that the Plan does not have to pay for the needle 
insertion(s) without injection(s); 1 or 2 muscle(s) provided on October 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0220 and D0230) and 
the unspecified restorative procedure (D2999) for tooth #12 provided on April 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental claim. The 
Plan denied your request. The Plan says your benefit for the intraoral radiographic image has already been 
exhausted. Also, the unspecified restorative procedure is not covered by the 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, certain limitations apply. The record 
shows the Plan paid for the intraoral radiographic image (D0220) on February 13, 2023; therefore, your benefit 
for the intraoral radiographic images was exhausted on the date of service of February 13, 2023. The 
unspecified restorative procedure is not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pay for the intraoral radiographic images (D0220 and D0230) and the unspecified 
restorative procedure (D2999) for tooth #12 provided on April 6, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rotary wing air transport (A0431) and rotary wing air 
mileage (A0436) provided on June 8, 2023. 
 
You asked the Plan to pay for rotary wing air transport (A0431) and rotary wing air mileage (A0436). You say 
that you provided emergent services, therefore, no authorization is required. The Plan denied your request. The 
Plan says there are closer facilities with gastroenterology services. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of rotary wing air transport (A0431) and rotary wing air mileage (A0436) have not been met. 
Therefore, we decided that the Plan does not have to pay for rotary wing air transport (A0431) and rotary wing 
air mileage (A0436) provided on June 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99358 billed for date of service May 16, 
2023, to May 17, 2023. 
 
You asked the Plan to pay for procedure code 99358. You say that the claim is billed correctly and 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 99358 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99358 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99358 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99358 billed for date of service May 16, 2023, to May 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computer-assisted robotic assistance surgical 
navigation procedure (20985). 
 
You asked the Plan to pre-approve a computer-assisted robotic assistance surgical navigation procedure. 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 a computer-assisted robotic assistance 
surgical navigation procedure. 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 benefit of computer assisted 
surgery when compared to open surgery. It is not medically needed. 
 
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 computer-assisted robotic assistance surgical navigation procedure have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a computer-assisted robotic 
assistance surgical navigation procedure (20985).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for spinal fusion surgery. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that you are appealing with supporting 
records. 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 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 a lack of large-volume, long-term, peer-reviewed outcome studies to support the use of bone marrow aspirate for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate for spinal fusion surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tempus xF. 
 
You asked the Plan to pre-approve Tempus xF. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that NGS is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Tempus xF. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found [state the medical finding(s) upon which 
the physician based his/her conclusion] 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tempus xF have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Tempus xF.