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

 
We decided that the Plan has to pay for practitioner services provided on March 20, 2023, billed with 
procedure code 99498. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says that procedure code 99498 was billed without 
the required 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, the CPT Code Manual definition of 
code 99498 is Advance care planning including the explanation and discussion of advance directives such as 
standard forms (with completion of such forms, when performed), by the physician or other qualified health 
care professional; each additional 30 minutes (List separately in addition to code for primary procedure). 
 
We find that CPT code 99498 is supported in the medical record. Specifically, it is documented that 52 minutes 
were spent on advance care planning. Also, the Plan's denial rationale is not valid as the referenced Local 
Coverage Article (LCA) is not applicable for the state of Michigan and there is no NCCI edit between codes 
99222 and 99498.  Based on this information, we decided that Medicare rules for coverage of the practitioner 
services provided have been met. Therefore, we decided that the Plan has to pay for practitioner services 
provided on March 20, 2023, billed with procedure code 99498.  
 
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: 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 
January 14, 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 January 14, 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 
February 17, 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 February 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 9, 2023, billed with 
codes 81209, 81223, 81241, 81250, 81305, 81307, 81311, 81320 and 81334. 
 
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 
February 9, 2023, billed with codes 81209, 81223, 81241, 81250, 81305, 81307, 81311, 81320 and 81334.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine months of continued home ventilator use. 
 
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 first three months are approved but nine continued months are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 the enrollee has chronic obstructive 
pulmonary disease (COPD), severe obesity, and pulmonary hypertension. The enrollee was hospitalized in May 
of 2019 with acute on chronic hypercarbic respiratory failure and was prescribed a home ventilator at that time. 
He is 100 percent compliant with the device. There is no documentation of trial and failure of bi-level positive 
airway pressure (BiPAP) therapy with average volume-assured pressure support (AVAPS). The nine months of 
use after the approved initial three months are not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve nine months of continued home ventilator use.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy (D3320), guided tissue regeneration 
(D4266 x2), and bone replacement grafts (D7953 x2). 
 
You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan 
denied your request. The Plan says your benefit for the endodontic therapy has already been exhausted. Guided 
tissue regeneration and bone replacement grafts are not covered 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, certain limitations apply. The record 
shows your benefit for the endodontic therapy was exhausted with the Plan's approval of two of these codes. 
Additionally, guided tissue regeneration and bone replacement grafts are not covered benefits. Therefore, we 
decided that the Plan does not have to pre-approve endodontic therapy (D3320), guided tissue regeneration 
(D4266 x2), and bone replacement grafts (D7953 x2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laminotomy procedure (63035). 
 
You asked the Plan to pre-approve a laminotomy. You say that a laminotomy is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says a laminotomy is 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 a laminotomy. Our reviewer says that 
the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation in the medical records of recent physical therapy for back 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 laminotomy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a laminotomy procedure (63035).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99309-25 and 15271 billed for date of 
service April 18, 2022.  
 
You asked the Plan to pay for procedure codes 99309-25 and 15271. You say that the claim is billed correctly 
and should be paid. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT codes 99309-25 and 15271 is 1. The MAI value for this code is 2. You billed 2 
units of this code, exceeding the MUE. Documentation shows that the Plan already paid for these codes, for the 
same date of service, on November 9, 2022. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 99309-25 and 15271 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 99309-25 and 15271 billed for date of service April 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 17004 and 17003 billed for date of service 
March 21, 2023.  
 
You asked the Plan to pay for procedure codes 17004 and 17003. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
Code 17003 is not separately payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 17004 is 1. The MAI value for this code is 2. You billed 6 units of this 
code, exceeding the MUE. 
 
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 17003 is a column II code to column I code 
17004 with a modifier indicator of 0. The column II code is therefore not payable. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 17004 and 17003 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 17004 and 
17003 billed for date of service March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 for date of service 
March 21, 2023. 
 
You asked the Plan to pay for procedure codes 96365, 96366, and 96521. 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. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 
We find that CPT codes 96365, 96366, and 96521 are not supported in the medical record. Specifically, the 
medical records indicate that outpatient intravenous insulin treatment (OIVIT) either pulsatile or continuous, by 
any means, guided by the results of measurements for: respiratory quotient; and/or, urine urea nitrogen (UUN); 
and/or, arterial, venous or capillary glucose; and/or potassium concentration was performed. There are more 
appropriate codes to be billed for the services rendered. In addition, the medical records provided do not show 
that code 96365, billed with the -59 modifier is a distinct procedural service. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 96365, 96366, and 96521 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 for date 
of service March 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 25, 2023, billed with 
codes 81306, 81335, 81225, 81226 and 81240. 
 
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 
January 25, 2023, billed with codes 81306, 81335, 81225, 81226 and 81240.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ViviGen Allograft. 
 
You asked the Plan to pre-approve ViviGen Allograft. You say that the requested ViviGen Allograft is 
medically necessary.  The Plan denied your request. The Plan says the requested ViviGen Allograft is 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 ViviGen Allograft. Our reviewer says 
that the requested ViviGen Allograft is not medically necessary.  Our physician reviewer found ViviGen 
Allograft is experimental in spine surgery. More research is needed 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 ViviGen Allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ViviGen Allograft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service February 15, 
2023, to February 21, 2023. 
 
You asked the Plan to pay for procedure code 99072. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99072 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 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99072 billed for date of service February 15, 2023, to February 21, 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 of service 
March 25, 2022. 
 
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 of service March 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 4, 2022, billed 
with codes 81215, 81321, 81323 and 81401. 
 
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 4, 2022, billed with codes 81215, 81321, 81323 and 81401.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95937 billed for date of service February 3, 
2022. 
 
You asked the Plan to pay for procedure code 95937. You say that this service was necessary and was reported 
appropriately. The Plan denied your request. The Plan says this service is not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any one method. 
 
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 95937. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found the procedure report documents train-of-four (T04) 
testing. Neuromuscular junction testing is a different procedure than train of four testing. There is no assigned 
code for train of four testing. Train-of-four monitoring is considered integral to intraoperative neuromonitoring 
and/or administration of anesthesia and, therefore, is not separately reportable. 
 
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 95937 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95937 billed for date of service February 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's quality of life is not good 
due to the pain.  The Plan denied your request. The Plan says the enrollee's pain is multifactorial.  
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation (or 
kyphoplasty) is only covered under certain medical indications. 
 
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 requested services. Our physician 
reviewer found that there is no documentation of fracture bracing. Therefore, the requested service is not 
medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a kyphoplasty procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar percutaneous vertebral augmentation (PVA). 
 
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 PVA 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no trial of fracture bracing. 
More conservative measures are needed prior to advancing to surgery. The criteria for coverage are not met and 
the PVA is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar percutaneous vertebral augmentation (PVA).