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

 
We decided that the Plan does not have to pay for procedure codes 99072 and 87631 billed for date of service 
July 25, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99072 is considered bundled and not separately payable and code 87631 
was not billed with the required DEX-Z code. 
 
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 these services have not been met.  
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 99072 and 87631 billed for date 
of service July 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81284 billed for date of service July 27, 
2022. 
 
You asked the Plan to pay for procedure code 81284. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 81284 is bundled into payment for code 81286. 
 
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 81284 
is a column II code to column I code 81286. 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 81284 billed for date of service July 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerecis Omega3, per sq cm (Q4158). 
 
You asked the Plan to pre-approve wound care. You say that you are requesting reconsideration because you 
could be at risk for losing your leg. The Plan denied your request. The Plan says the records do not show 
criteria for medical necessity. 
 
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 wound care. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found Medicare guidelines advise that chronic wounds are defined as wounds that do not respond to 
standard wound treatment for at least 30 days during organized comprehensive conservative therapy. A failed 
response is defined as an ulcer or skin deficit that has failed to respond to documented appropriate wound care 
measures, has increased in size or depth, or has not changed in baseline size or depth and has no indication that 
improvement is likely. In this particular case, the medical documentation does not support that this wound is a 
chronic nonhealing wound that would require some sort of advanced skin substitute application. The enclosed 
progress notes do not advise on a baseline wound measurement, nor do they advise on subsequent foot wound 
measurements (which would allow for determination of a chronic nonhealing wound). Therefore, the wound 
cannot be considered nonhealing and the Kerecis wound dressing cannot be considered medically reasonable or 
necessary for you 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 wound care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Kerecis Omega3, per sq cm (Q4158).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on May 19, 2022, to May 26, 
2022. 
 
You asked the Plan to pay for chiropractic services. You say that you were told that you did not need a referral. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for chiropractic services 
provided on May 19, 2022, to May 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81340, 81342, and 81405 billed for date of 
service March 3, 2022. 
 You asked the Plan to pay for procedure codes 81340, 81342, and 81405. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for codes 81340, 81342, and 81405 is 
bundled into payment for code 81455. 
 
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 codes 
81340, 81342, and 81405 are column II codes to column I code 81455. 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 codes 81340, 81342, and 81405 
billed for date of service March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95886, 95955, 95908, and 95927 for date of 
service July 23, 2021. 
 
You asked the Plan to pay for procedure codes 95886, 95955, 95908, and 95927. 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. 
 
We find that CPT codes 95886, 95955, 95908, and 95927 are not supported in the medical record. Specifically, 
the technical report did not include documentation of a complete needle electromyography, per each extremity 
with related paraspinal areas when performed, done with nerve conduction, amplitude and latency/velocity 
study; for five or more muscles studied, innervated by three or more nerves or four or more spinal levels (listed 
separately in addition to code for primary procedure); therefore, code 95886 cannot be verified.  
 
The technical report did not include documentation of electroencephalogram (EEG) during nonintracranial 
surgery (carotid surgery); therefore, code 95955 cannot be verified. 
 
The technical report did not include documentation of nerve conduction studies, for 3-4 studies; therefore, code 
95908 cannot be verified. 
 
The technical report did not include documentation of short-latency somatosensory evoked potential study, 
stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system, in the trunk or 
head; therefore, code 95927 cannot be verified. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 95886, 95955, 
95908, and 95927 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 95886, 95955, 95908, and 95927 for date of service July 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95911 billed for date of service November 9, 
2022.  

You asked the Plan to pay for procedure code 95911. You say that this service is supported in the medical 
records. The Plan denied your request. The Plan says payment for code 95911 is bundled into payment for code 
95870. 
 
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 95911 
is a column II code to column I code 95870 with a modifier indicator of 0. The column II 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 code 95911 billed for date of service November 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim crown (D2799 x 2) and surgical procedure 
for isolation of tooth with rubber dam (D3910). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says these services are not covered under the Plan's 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 pre-approve an 
interim crown (D2799 x 2) and surgical procedure for isolation of tooth with rubber dam (D3910).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 63052 rendered on December 7, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the services are not supported without the required documentation. 
 
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 63052 is "Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of 
spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody 
arthrodesis, lumbar; single vertebral segment (List separately in addition to code for primary procedure)." 
 
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 the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the procedure details cite a bilateral 
hemilaminotomy was performed, bilateral partial medial facetectomy, and bilateral nerve root decompression 
to decompress the bilateral lateral recess stenosis was performed prior to placement of the screws. It was after 
x-rays showed inadequate lordosis that the osteotomy was performed. Therefore, the records do support that 
CPT 63052 was a separate and distinct procedure from CPT 22214. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
procedure code 63052 rendered on December 7, 2022.  
 
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 procedure code 87086 for date of service November 15, 
2022. 
 
You asked the Plan to pay for procedure code 87086. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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 87086 is culture, bacterial; quantitative colony count, urine. 
 
We find that CPT code 87086 is not supported in the medical record. Specifically, bacterial cultures are only 
covered when billed with a covered diagnosis code. Any diagnosis code not listed is not covered. 
This service was billed with diagnosis (Malignant neoplasm of posterior wall of bladder). This is not listed as 
an appropriate indication for code 87086. Based on this information, we decided that Medicare rules for 
coverage of procedure code 87086 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 87086 for date of service November 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen testing by nucleic acid provided on 
September 6, 2022, for cytomegalovirus, herpes virus-6, and streptococcus group B.  
 
You asked the Plan to pay for the pathogen testing. You say that this should be paid due to medical necessity. 
The Plan denied your request. The Plan says the three codes that remain denied 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.  

We find that the testing at issue is not supported in the medical record. Specifically, the lab report does not 
document results for cytomegalovirus, herpes virus-6, and streptococcus group B. Based on this information, 
we decided that Medicare rules for coverage of the pathogen testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the respiratory pathogen testing by nucleic acid provided on September 6, 
2022, for cytomegalovirus, herpes virus-6, and streptococcus group B.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80050, 82565, 82947, 84132, 84155, 84295, 
and 84520 for date of service January 26, 2021. 
 
You asked the Plan to pay for procedure codes 80050, 82565, 82947, 84132, 84155, 84295, and 84520. You 
say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not 
payable as billed. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. The rules also say that providers must report services correctly. Providers must report services 
with the appropriate CPT code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. We find that CPT codes 82565, 82947, 84132, 84155, 84295 and 84520 are not 
supported in the medical record. Specifically, the medical records submitted do not include a signed physician 
order or signed laboratory requisition for the billed tests. Also, the medical records received do not support that 
the procedure or service was distinct or independent from other services performed. This means the billed code, 
modifier and place of service cannot be verified. Therefore, we decided that the Plan does not have to pay for 
procedure codes 80050, 82565, 82947, 84132, 84155, 84295, and 84520 for date of service January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the semi-precision attachment placement (D6192 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says this service is not a covered benefit under the enrollees dental plan. 
 
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 pre-approve the 
semi-precision attachment placement (D6192 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95908, 95955, 95861, 95868, 95937, and 
95927 for date of service February 26, 2021. 
 
You asked the Plan to pay for procedure codes 95908, 95955, 95861, 95868, 95937, and 95927. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 
billed. 
 
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 95908 is a column II code to column I codes 95861 and 95868 with a 
modifier indicator of 0. The column II code is therefore not payable. 
 
We find that CPT codes 95955, 95861, 95868, 95937, and 95927 are not supported in the medical record. 
Specifically, the technical report did not include documentation of an electroencephalogram (EEG) during 
nonintracranial surgery (carotid surgery); therefore, code 95955 cannot be verified. 
 
The technical report did not include documentation of needle electromyography, 2 extremities with or without 
related paraspinal areas; therefore, code 95861 cannot be verified. 
 
The technical report did not include documentation of a needle electromyography, for cranial nerve supplied 
muscles, for bilateral studies; therefore, code 95868 cannot be verified. 
 
The technical report did not include documentation of neuromuscular junction testing (repetitive stimulation, 
paired stimuli) for each nerve, by any 1 method; therefore, code 95937 cannot be verified. 
 
The technical report did not include documentation of short-latency somatosensory evoked potential study, 
stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system, in the trunk or 
head; therefore, code 95927 cannot be verified.  
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 95908, 95955, 
95861, 95868, 95937, and 95927 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 95908, 95955, 95861, 95868, 95937, and 95927 for date of service February 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service August 24, 
2022. 
 
You asked the Plan to pay for procedure code 87634. You say that you have correctly billed the services at 
issue. The Plan denied your request. The Plan says payment for code 87634 is bundled into payment for code 
87632. 
 
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 87634 
is a column II code to column I code 87632. 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 87634 billed for date of service August 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 1, 2022, to July 
30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have correctly billed the 
services at issue. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 1, 2022, to July 30, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary to ensure that 
the enrollee reaches their maximum function. The Plan denied your request. The Plan says the services are no 
longer medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.