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

 
We decided that the Plan does not have to pay for the immunoglobulin paraprotein (m-protein), qualitative, 
immunoprecipitation and mass spectrometry, blood or urine, including isotype (0077U) provided October 24, 
2022. 
 
You asked the Plan to pay for the laboratory service. You say that this test was ordered by a treating physician 
who makes the professional determination of diagnosis and medical necessity to successfully treat their 
patients.  The Plan denied your request. The Plan says this service does not meet the coverage requirements in 
the applicable Local Coverage Determination (LCD) or National Coverage Determination (NCD).  
 
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 pay for the laboratory service. 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 documentation as to why this test was medically necessary and supported 
by medical evidence for this clinical scenario. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the immunoglobulin paraprotein (m-protein), qualitative, immunoprecipitation and 
mass spectrometry, blood or urine, including isotype (0077U) provided October 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87150 billed for date of service January 5, 
2023. 
 
You asked the Plan to pay for procedure code 87150. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says this service is not supported for separate payment. 
 
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 87150 is a column II code to column I code 87500; however, 87150 
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 procedure code 87150. Our reviewer says that this service is 
not supported for separate billing. Our reviewer found this test is included in procedure code 87500 and cannot 
be verified as a separately identifiable procedure based on the documentation provided. 
 
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 87150 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87150 billed for date of service January 5, 2023.
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 May 11, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. 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 May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gingivectomy (D4211) provided on April 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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 a 
gingivectomy (D4211) provided on April 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service August 6, 
2022. 
 
You asked the Plan to pay for procedure code 87640. You say that this service was reported appropriately and 
is supported in the medical record. The Plan denied your request. The Plan says this code is not supported for 
separate payment. 
 
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 87640 is a column II code to column I code 87641; however, 87640 
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 procedure code 87640. Our reviewer says that this code is 
not supported for separate billing. Our reviewer found the laboratory report does not include documentation to 
support a separate procedure. The report documents Staphylococcus aureus, methicillin resistant was 
performed, and in this case CPT 87641 would be reported. 
 
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 87640 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87640 billed for date of service August 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75710 billed for date of service February 9, 
2023. 
 
You asked the Plan to pay for procedure code 75710. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says the payment for code 75710 is included in 
the payment for code 37226. Although a modifier was used, the records provided do not support the use of this 
modifier. 
 
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 75710 is a column II code to column I code 37226; however, 75710 
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 procedure code 75710. Our reviewer says that this service is 
not supported for separate payment. Our reviewer found the procedure report describes angiography performed 
for follow up of the revascularization procedure, which in this case would be included in the primary 
procedure, CPT 37226. 
 
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 75710 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 75710 billed for date of service February 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided on December 9, 
2022, by an OON provider.  
 
You asked the Plan to pay for a compression device. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says this service was not authorized. 
 
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 a pneumatic compression device provided on 
December 9, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the office visits provided on December 27, 2022, 
and February 28, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to reimburse you for the office visits provided on December 27, 2022, and February 28, 
2023. You say that you found this provider on your own. You say that your plan waived the need for a referral. 
You also say that you should be reimbursed for these services. The Plan denied your request. The Plan says 
prior authorization was not obtained. 
 
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 reimburse you for care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to reimburse you for these items/services. 
Therefore, we decided that the Plan does not have to reimburse you for the office visits provided on December 
27, 2022, and February 28, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic (D6245) provided on February 24, 2023. 
 
You asked the Plan to pay for D6245. You say that you needed this dental work. The Plan denied your request. 
The Plan says this is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a pontic 
(D6245) provided on February 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildups, including any pins when required  
(D2950 x 2). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested dental items are not covered under the 
supplemental dental policy.  
  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildups, including any pins when required (D2950 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the added tooth to an existing partial denture (D5650) 
provided on March 24, 2023. 
 
You asked the Plan to pay for the dental item. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this dental item 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental item provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the added tooth 
to an existing partial denture (D5650) provided on March 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit for the evaluation and 
management of an established patient (99215) provide don February 15, 2023. 
 
You asked the Plan to pay for an office visit. You say that you disagree with the denial and have submitted 
medical records for review. The Plan denied your request. The Plan says code 99215 remains not supported. 
The medical records submitted do not support high level of medical decision making or total time required of 
the code billed. 
 
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 pay for an office visit. 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 a history of endometrial adenocarcinoma, hypothyroidism, and 
supraventricular tachycardia who presents on February 15, 2023, for the evaluation of constipation. On 
September 9, she underwent a total hysterectomy. Since then, her constipation has progressed. She feels 
significant abdominal bloating and gas, with strong urge but without ability to defecate. She tried using Miralax 
once or twice daily, but this worsened her abdominal symptoms. She also tried using prune juice, and 
suppositories without significant benefit. Currently she is on yogurt and prune juice, which has been helpful. 
She reports significant straining associated with defecation. She has urge to defecate but feels that she has a 
difficult time pushing her stool out. Her stools are loose and soft in caliber. The review has determined that the 
records supported that there was a medically appropriate history and/or examination but not high level of 
medical decision making or that 40-54 minutes of total time were spent during this encounter. 
 
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 office visit have not been met. Therefore, we decided that the Plan does not 
have to pay for an office or other outpatient visit for the evaluation and management of an established patient 
(99215) provide don February 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 72040, 70100, 70310, 71045, 74240, and 
74230 provided on April 27, 2022. 
 
You asked the Plan to pay for procedure codes 72040, 70100, 70310, 71045, 74240, and 74230. 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 as billed. 
 
The Plan must follow Medicare rules. The rules say that for mobile units serving an entity with its own POS 
code, the entity's POS code should be reported.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services have not been met. The documentation supports that the enrollee was at a 
skilled nursing facility on the date of service. As such, the use of the office POS code is not appropriate. 
Therefore, we decided that the Plan does not have to pay for procedure codes 72040, 70100, 70310, 71045, 
74240, and 74230 provided on April 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service September 2, 
2022. 
 
You asked the Plan to pay for procedure code 81345. You say that this service should be covered. The Plan 
denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service September 2, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic image (D0230), a cone beam 
(D0367), and the pulp vitality tests (D0460) provided on March 21, 2023. 
  
You asked the Plan to pay for the dental services. You say that you were in severe pain and the Plan told you 
that root canals were covered at 100%. The Plan denied your request. The Plan says your benefit for the 
intraoral radiographic image has already been exhausted. Also, the denial of payment for the cone beam and the 
pulp vitality tests is correct because they 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, certain limitations apply. The record 
shows the Plan paid for the intraoral radiographic image (D0220) on March 21, 2023; therefore, your benefit 
for the intraoral radiographic image (D0230) was exhausted on the date of service of March 21, 2023. The cone 
beam and the pulp vitality tests are not covered under the Plan's dental benefit. Therefore, we decided that the 
Plan does not have to pay for the intraoral radiographic image (D0230), a cone beam (D0367), and the pulp 
vitality tests (D0460) provided on March 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve 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 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 as discussed above. 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87491, 87640, 87641 and 87500 billed for 
date of service February 6, 2023. 
 
You asked the Plan to pay for procedure codes 87491, 87640, 87641 and 87500. You say that these services 
were reported appropriately and are supported in the medical record. The Plan denied your request. The Plan 
says these services are not supported in the records provided. 
 
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 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 87491, 87640, 87641 and 87500. Our 
reviewer says that these codes are not supported in the medical records provided. Our reviewer found there are 
no results or evidence proving that infectious agent detection by probe technique was performed for chlamydia 
trachomatis, vancomycin resistance, staph aureus, and/or methicillin resistant staph aureus. 
 
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 87491, 87640, 87641 and 87500 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87491, 87640, 87641 and 87500 billed for 
date of service February 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 10, 2022, billed 
with multiple codes including 81345. 
 
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 
November 10, 2022, billed with multiple codes including 81345.