Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft at the time of implant placement (D6104), 
surgical placement of an implant body: endosteal implant (D6010), and guided tissue regeneration, natural 
teeth-resorbable barrier, per site (D4266). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a bone graft 
at the time of implant placement (D6104), surgical placement of an implant body: endosteal implant (D6010), 
and guided tissue regeneration, natural teeth-resorbable barrier, per site (D4266).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services coded as 99214 and 
radiology services coded as 74230, 74240, 72040, and 71045 performed on January 30, 2023. 
 
You asked the Plan to pay for services performed on January 30, 2023. You say that the services performed on 
January 30, 2023, should be covered because they are supported in the documentation. The Plan denied your 
request. The Plan says codes 74230 and 74240 are not covered benefits because they are listed in the 
Exclusions from Coverage as Portable X-Ray Services section of the Medicare Benefit Policy Manual. Codes 
99214, 71045, and 72040 are not covered because they were billed with an inappropriate POS. 
 
The Plan must follow Medicare rules. Medicare rules say that radiology services performed in the mobile 
setting are not eligible for reimbursement if they are listed in the Exclusions from Coverage as Portable X-Ray 
Services section of the Medicare Benefit Policy Manual. Medicare rules also state that claims must be billed 
with the appropriate POS.  
 
We looked at the file and Medicare rules. Documentation provided shows codes 74230 and 74240 were 
performed in a mobile unit setting with the use of fluoroscopy. Therefore, they are not covered and are 
excluded under the portable x-ray provision. Codes 99214, 71045, and 72040 were billed with POS 11, 
indicating an office setting. However, documentation shows these services were performed in a mobile setting. 
There is no evidence the services were provided in an office setting.  Based on this information, we decided 
that Medicare rules for coverage of services performed on January 30, 2023, have not been met. Therefore, we 
decided that the Plan does not have to pay for evaluation and management services coded as 99214 and 
radiology services coded as 74230, 74240, 72040, and 71045 performed on January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341), osseous 
surgery (including elevation of a full thickness flap and closure) (D4260), osseous surgery including flap entry 
and closure (D4261), and drugs or medicaments dispensed in the office for home use (D9630). 
 
You asked the Plan to pre-approve the dental services. You say that you paid for dental service, which is 
unrendered due to the Plan's denials of periodontics. You also say you need periodontic services. The Plan 
denied your request. The Plan says your benefit for periodontal scaling and root planing (D4341) has already 
been exhausted. The Plan also says that osseous surgery (including elevation of a full thickness flap and 
closure) (D4260), osseous surgery including flap entry and closure (D4261), and drugs or medicaments 
dispensed in the office for home use (D9630) are 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, certain limitations apply. The record 
shows your benefit for the periodontal scaling and root planing (D4341) was exhausted on dates of service 
February 16, 2022, and February 17, 2022. The record also shows that your benefit for osseous surgery 
(including elevation of a full thickness flap and closure) (D4260), osseous surgery including flap entry and 
closure (D4261), and drugs or medicaments dispensed in the office for home use (D9630) is not a covered 
benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing 
(D4341), osseous surgery (including elevation of a full thickness flap and closure) (D4260), osseous surgery 
including flap entry and closure (D4261), and drugs or medicaments dispensed in the office for home use 
(D9630).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 1, 2023, billed with 
procedure codes 96365-59, 96366-59, 96521, J1817, and G0108. 
 
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 codes. 
 
The Plan must follow Medicare rules. Medicare rules say that services comprising an Outpatient Intravenous 
Insulin Therapy regimen are nationally non-covered under Medicare when furnished pursuant to an OIVIT 
regimen.  
 We looked at 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. The billed service is not payable as it is a 
non-covered service. Therefore, we decided that the Plan does not have to pay for practitioner services 
provided on March 1, 2023, billed with procedure codes 96365-59, 96366-59, 96521, J1817, and G0108.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on July 28, 2022. 
 
You asked the Plan to pay for the refraction. You say that you were told that routine vision procedures are 
covered by Medicare/Medicaid with no copayment. You say you would have chosen another plan if you had 
known it was not covered. The Plan denied your request. The Plan says the refraction is not payable without a 
routine eye exam. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers the refraction when billed part of the routine eye examination. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was billed as a part of a medical eye 
examination. Based on this information, we decided that the Plan's rules for coverage of the refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for the refraction provided on July 28, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test provided on April 27, 2023, billed with 
codes 87486, 87502, 87503, 87541, 87581, 87651, 87798 and U0005. 
 
You asked the Plan to pay for the laboratory test 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 a 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 a laboratory 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 laboratory test 
billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test 
provided on April 27, 2023, billed with codes 87486, 87502, 87503, 87541, 87581, 87651, 87798 and U0005.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 25, 2023, billed with 
evaluation and management code 99232-GC. 
 
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 that the level of care 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 99232 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded. 
 We find that CPT code 99232 is not supported in the medical record. Specifically, the documentation shows 
that the total time spent is 25 minutes, which does not meet the time requirement for the billed code. 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 April 
25, 2023, billed with evaluation and management code 99232-GC.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunoassay, analyte, quantitative, radiopharmaceutical 
technique (83519) provided September 29, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you are appealing the Plan decision 
regarding denial of payment. The Plan denied your request. The Plan says per Medicare guidelines, the 
procedure code is a non-covered code, or the modifier is a non-covered 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 find that CPT code 83519-GY is not supported in the medical record. Specifically, the claim 
was billed with the GY modifier. The GY modifier indicates that an item or service is statutorily excluded or 
does not meet the definition of any Medicare benefit. 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 immunoassay, analyte, quantitative, radiopharmaceutical technique (83519) provided 
September 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory/pathology services (88305, 88312, 87150 and 
88311) provided on March 4, 2023. 
 You asked the Plan to pay for laboratory/pathology services. You say that these services were necessary and 
are supported in the medical record. The Plan denied your request. The Plan says the medical records provided 
are missing a laboratory order/requisition form to support that they were requested by the enrollee's treating 
physician. 
 
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 laboratory/pathology services have 
been met. Specifically, the requisition form provided includes an illegible signature, and there are no medical 
records or physician notes to support the medical necessity of these services and that they are requested by the 
enrollee's treating physician. Therefore, we decided that the Plan does not have to pay for laboratory/pathology 
services (88305, 88312, 87150 and 88311) provided on March 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assay of free thyroxine (84439) provided on August 4, 2022. 
 
You asked the Plan to pay for assay of free thyroxine. You say that this test was necessary and was reported 
appropriately. The Plan denied your request. The Plan says this test was not indicated as requested on the 
physician order form. 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 assay of free thyroxine have been met. 
Specifically, the laboratory order submitted clearly shows that assay of free thyroxine was not among those 
requested for testing. There is no evidence that this service was necessary or requested by the enrollee's treating 
physician. Therefore, we decided that the Plan does not have to pay for assay of free thyroxine (84439) 
provided on August 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on November 4, 2022, billed 
with codes 87500, 87511, 87529, 87640, 87641, 87651, 87653, 87798, 87481, 87640 and 87801. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing 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 a 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 a laboratory 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 laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on November 4, 2022, billed with codes 87500, 87511, 87529, 87640, 87641, 87651, 87653, 
87798, 87481, 87640 and 87801.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found additional studies are needed to 
validate the benefit of the Intracept procedure. The records document that you have other diagnoses on spinal 
imaging which may be the cause of your back pain. The Intracept procedure is not reasonable or medically 
necessary at this time. 
 We looked at this physician's review, the file, and Medicare rules. 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 pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the enrollee would benefit from the 
requested procedure. The Plan denied your request. The Plan says the requested procedure does not meet the 
medical requirements for approval. 
 
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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered 
investigational and not medically necessary for the treatment of chronic knee pain.  
 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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99349 billed for the following dates of service: June 12, 
2022, June 19, 2022, July 24, 2022, to July 31, 2022, August 7, 2022, to August 14, 2022, August 21, 2022, to 
August 28, 2022, and October 9, 2022. 
 
You asked the Plan to pay for code 99349. You say that you have provided medical records to support 
payment. 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 29580 
provided on June 12, 2022, June 19, 2022, July 24, 2022, to July 31, 2022, August 7, 2022, to August 14, 2022, 
August 21, 2022, to August 28, 2022, and October 9, 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 code 
99349 billed for the following dates of service: June 12, 2022, June 19, 2022, July 24, 2022, to July 31, 2022, 
August 7, 2022, to August 14, 2022, August 21, 2022, to August 28, 2022, and October 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (86803, 87389) provided on March 8, 2023. 
 You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this test was for screening purposes and is non-covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, Human Immunodeficiency Virus (HIV) Testing and Hepatitis C screening, was 
requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. 
Therefore, we decided that the Plan does not have to pay for lab services (86803, 87389) provided on March 8, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 13, 2023, to 
March 13, 2023. 
 You asked the Plan to pay for the home health services. You say that the bill type is valid, so this claim should 
be reprocessed. 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 December 15, 2022. The NOA was not received by the Plan until April 17, 
2023. 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 13, 2023, to March 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on May 9, 2023, billed with 
codes 87481, 87491, 87563, 87640, 87653, 87798, 87641 and 87500. 
 
You asked the Plan to pay for the laboratory panel. 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 a 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 a laboratory 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 laboratory 
panel have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory panel 
provided on May 9, 2023, billed with codes 87481, 87491, 87563, 87640, 87653, 87798, 87641 and 87500.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of intra-socket biological dressing 
(D7922) for tooth #11. 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because the placement of intra-socket biological dressing 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, 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 
placement of intra-socket biological dressing (D7922) for tooth #11.