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

 
We decided that the Plan does not have to pay for procedure codes 83789 and G0480 billed for date of service 
July 6, 2023. 
 
You asked the Plan to pay for procedure codes 83789 and G0480. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes 83789 and G0480 are bundled into 
payment for other codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules state that providers may bill services 
with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 
 
In this case, we have confirmed that code 83789 is a column II code to column I code 80307. We have also 
confirmed that code G0480 is a column two code to column one code 80307 with a modifier indicator of 0. 
While these services were billed with modifier -59, the medical records provided do not show that the services 
billed with the -59 modifier were a distinct procedural service. The column two code is therefore not payable. 
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 codes 83789 and G0480 billed for date of service July 6, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional home health skilled nursing visits. 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation does not specify any acute clinical status, medication or plan of care changes, or complex 
wound care needed (simple gauze dressing 2-3 times per week documented). The records do not show that 4 
additional home health skilled nursing visits are required to effectively provide treatment, care, and/or services 
in order to improve your condition, or to establish/perform a maintenance program to maintain your condition 
and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 additional home health skilled nursing visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete upper denture (D5810), a complete lower denture 
(D5811), alveoloplasty (D7310 and D7311) for tooth #23 and #27, a consultation (D9310), and the therapeutic 
drugs (D9610) provided on May 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dental services should be 100% covered by 
Medicare. The Plan denied your request. The Plan says the denial of payment for these services is correct 
because the dentures, the alveoloplasty, the consultation, and the therapeutic drugs 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. 
 
The requested dentures, the alveoloplasty, the consultation, and the therapeutic drugs in dispute meets the 
Medicare definition of dental, since it is a service which involved the care and treatment of teeth or structures 
directly supporting the teeth. The dentures, the alveoloplasty, the consultation, and the therapeutic drugs do not 
fall under any of Medicare exceptions for coverage of non-routine dental care. 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 complete upper denture (D5810), a 
complete lower denture (D5811), alveoloplasty (D7310 and D7311) for tooth #23 and #27, a consultation 
(D9310), and the therapeutic drugs (D9610) provided on May 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing (83789) provided on August 1, 2023. 
 
You asked the Plan to pay for validity testing. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of validity testing have not been met. Specifically, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for validity testing (83789) provided on August 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and a 
complete series of radiographic images (D0210). 
 
You asked the Plan to pre-approve the dental services. You say that this dental work is medically necessary. 
The Plan denied your request. The Plan says your benefit for the requested item or service 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 requested item or service was exhausted on date of service May 18, 2023. Therefore, 
we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and a 
complete series of radiographic images (D0210).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional home health physical therapy visits (G0151 
x4). 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation does not specify any unmet appropriate home health physical therapy goals. The records do not 
show that 4 additional home health physical therapy visits are required to effectively provide treatment, care, 
and/or services in order to improve your level of function, or to establish/perform a maintenance program to 
maintain your level of function and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 additional home health physical therapy visits (G0151 x4).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from July 16, 2023, through 
July 20, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee was admitted on July 4, 2023 with an infected fistula and a blood infection. She was 
placed on intravenous antibiotics. Repeat blood cultures were obtained on July 5, 2023. A catheter was to be 
placed in the enrollee's vein to receive dialysis if the blood infection had cleared. The review indicates that the 
record showed that at the time of the inpatient admission it was reasonable for the admitting physician to 
expect that the enrollee's necessary hospital care (including earlier emergency department (ED) and/or 
observation care) would span two midnights with supporting documentation of the enrollee's history and 
comorbidities, signs and symptoms, current medical needs, and risk of an adverse event. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from July 16, 2023, through July 20, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain fused to high noble metal (D2750) for 
teeth numbers 7 and 10. 
 
You asked the Plan to pre-approve crown - porcelain fused to high noble metal (D2750) for teeth numbers 7 
and 10. You say that you were in the hospital on October 10, 2023, which is why you were not able to attend 
your appointment. The Plan denied your request. The Plan says this is not medically necessary. 
 
 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. The Plan covers crown - 
porcelain fused to high noble metal (D2750) for teeth numbers 7 and 10 when the services are medically 
necessary and reasonable.  
 
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 crown - porcelain fused to high noble 
metal (D2750) for teeth numbers 7 and 10. Our reviewer says that the service is not medically necessary. Our 
physician reviewer found there are more conservative treatment options to restore the wear on these teeth. Our 
physician reviewer also says there was not narrative included that stated why more conservative treatment 
options for teeth numbers 7 and 10 cannot be done. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of crown - porcelain fused to high noble metal (D2750) for teeth numbers 7 and 10 
have not been met. Therefore, we decided that the Plan does not have to pre-approve crown - porcelain fused to 
high noble metal (D2750) for teeth numbers 7 and 10.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pay for a CPM device. We decided that the Plan does not have to pay for a 
progress monitor.  
 
You asked the Plan to pay for a continuous passive motion (CPM) device and progress monitor. The Plan says 
that the services are not a covered benefit. 
 
We decided that the Plan has to pay for a CPM device.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The authorization request provided in the case 
file shows that a continuous passive motion device, coded E0935, was requested for use after knee surgery. 
Based on this information, we decided that the device was coded correctly. Therefore, we decided that the Plan 
has to pay for the requested CPM device.  
 
We also decided that the Plan does not have to pay for a progress monitor. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
We looked at the file and the rules. We find that the Bluetooth-enabled progress monitor does not serve a 
purpose that is primarily medical in nature. Based on this information, we decided that the Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for a progress monitor. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for dates of service May 23, 
2023, to May 26, 2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed code 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 99233 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 high level of medical decision making. 
 
The file shows that procedure code 99233 was billed for dates of service May 23, 25, and 26, 2023. 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 billed services. Our reviewer found that the 
documentation from the dates at issue describe the enrollee as alert, hemodynamically stable, with resolved 
pneumonia and kidney insufficiency, with plans for routine trach care. Intravenous fluids were stopped as the 
enrollee was tolerating tube feeds, and continued weaning which was being tolerated on trach collar. The 
progress notes did not support a high level of medical decision-making.  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99233 billed for dates of service May 23, 2023, to May 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the core buildup (D2950) for tooth #32 and to pay for 
the core buildup (D2950) for tooth #2 provided on May 2, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you submitted all the proper 
documentation with the dental codes and the Plan should cover up to your annual benefit. The Plan denied your 
request. The Plan says your dental maximum benefit for the year 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 the Plan paid $72 for dental services on February 13, 2023. On May 15, 2023, which was processed 
prior to the claim for May 2, 2023, the Plan paid $200 for dental services. On September 6, 2023, which was 
processed prior to the claim for May 2, 2023, the Plan paid $55 for dental services. On May 2, 2023, the Plan 
paid $1,673 for dental services. For the year of 2023 the Plan paid $2,000 ($72 paid + $200 paid + $55 paid + 
$1,673 paid) for dental services; therefore, your annual dental maximum benefit for the year of 2023 was 
exhausted on the date of service of May 2, 2023. Therefore, we decided that the Plan does not have to pay more 
for the core buildup (D2950) for tooth #32 and to pay for the core buildup (D2950) for tooth #2 provided on 
May 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing billed with codes 8481, 87640, 87652, 
87798 x13, 87799-59 and 87799 x2, provided July 25, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that this test was ordered based upon the treating 
physician's clinical training and medical necessity. 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. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory testing billed with codes 8481, 87640, 87652, 87798 x13, 87799-
59 and 87799 x2, provided July 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
May 1, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service May 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate. 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that this is medically necessary for the 
enrollee. 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 the bone marrow aspirate. Our reviewer 
says that the requested bone marrow aspirate is not considered medically reasonable and necessary in this case. 
Our physician reviewer found bone marrow aspirate remains experimental. More research is needed to show safety and efficacy when used as bone graft material. Therefore, the reviewer found that the requested bone 
marrow aspirate is not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax (S9999) provided on July 13, 2023. 
 
You asked the Plan to pay for the sales tax (S9999). You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says they will reimburse you $903.98 for procedure 
code A9270. You will be responsible for a $225.99 coinsurance applied to procedure code A9270 and for the 
sales tax (S9999). 
 
The Plan must follow Medicare rules. The rules say contractors do not make any additional payment for sales 
taxes. Therefore, we decided that the Plan does not have to pay for the sales tax (S9999) provided on July 13, 
2023.