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

 
We decided that the Plan does not have to pre-approve the implant supported porcelain/ceramic crown tooth 19 
(D6065), and custom fabricated abutment - includes placement tooth 19 (D6057). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says the benefit 
for the implant supported porcelain/ceramic crown and custom fabricated abutment - includes placement 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 benefit for the implant supported porcelain/ceramic crown (D6065), and custom fabricated abutment 
- includes placement (D6057) was exhausted on date of service September 16, 2021. Therefore, we decided 
that the Plan does not have to pre-approve the implant supported porcelain/ceramic crown tooth 19 (D6065), 
and custom fabricated abutment - includes placement tooth 19 (D6057).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator for 9 months (E0466). 
 
You asked the Plan to pre-approve a home ventilator for 9 months. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
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 a home ventilator for 9 months. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found continuation of the 
home ventilator is not medically necessary. The ventilator is being used in a mode that can be provided with 
bilevel positive airway pressure (BiPAP). There is no documentation of failure of BiPAP with average volume-
assured pressure support (AVAPS) as an outpatient. The plan has approved the home ventilator for 3 months to 
allow time for transition to BiPAP. 
 
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 home ventilator for 9 months have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a home ventilator for 9 months (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798-XU billed for date 
of service October 5, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653 and 87798-XU. You say that these services are 
supported in the medical record and were reported correctly. The Plan denied your request. The Plan says these 
services are not supported for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that codes 87481, 87653 and 87798 are column II codes to column I code 
87801; Codes 87481 and 87653 have not been billed with an appropriate modifier to bypass the edit. Based on 
the claim submitted, Medicare billing criteria have not been met for codes 87481 and 87653. However, code 
87798 was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 87798-XU. Our reviewer says that code 
87798 is not supported for separate reporting with modifier XU. Our reviewer found the laboratory report does 
not include documentation to support this service was an unusual non-overlapping service from CPT 87801 
which includes multiple organisms. Therefore, this procedure code cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87481, 87653 and 87798-XU have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798-XU billed for date of 
service October 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 9 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 9 months. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 a ventilator for 9 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
with auto-EPAP (AE) which could be provided by a bilevel positive airway pressure (BiPAP) device with 
AVAPS and a back-up rate. Provided records do not document trial and failure of a BiPAP device with 
AVAPS and a back-up rate. 
 
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 ventilator for 9 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 9 months (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 17, 2023. 
 
You asked the Plan to pay for the lab services. You say that the treatment sought was medically necessary. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. The gene panel was billed with multiple codes, 
including code 81345. The gene panel was not billed with single code as required. Based on this information, 
we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on January 17, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 23650 billed for date of service October 4, 2022. 
 
You asked the Plan to pay for the billed services. You say that the documents support the level of service. The 
Plan denied your request. The Plan says that the provider did not bill as required by Medicare regulations. 
 
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 code 23650 was billed with an emergency department place of service code. The physician 
who performs the emergency room service bills for the surgical procedure without a modifier. Based on this 
information, we decided that Medicare rules for coverage of the billed services have been met. Therefore, we 
decided that the Plan has to pay for procedure code 23650 billed for date of service October 4, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the occupational therapy services provided 
from July 16, 2019, to February 17, 2020. 
 
You asked the Plan to waive the copayments for the occupational therapy services. You say that you have gone 
to this provider for many years without receiving any bills. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your 2019 contract with the Plan clearly says that you must pay a 
$25 copayment for occupational therapy services. Your 2020 contract with the Plan clearly says that you must 
pay a $20 copayment for occupational therapy services. 
 
You have been asked to pay a $25 copayment for each occupational therapy service provided in 2019. You 
have also been asked to pay a $20 copayment for each occupational therapy service provided in 2020. This 
item/service falls within the outpatient rehabilitation services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayments for the occupational therapy services provided from July 16, 2019, to February 17, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the abutment supported porcelain fused to metal crown 
tooth #19 (high noble metal) (D6059), custom fabricated abutment - includes placement tooth #19 (D6057), 
and surgical placement of implant body: endosteal implant tooth #19 (D6010). 
 
You asked the Plan to pre-approve the dental codes represented by D2750, D6059, D6057 and D6010. You say 
that you lost tooth #19 last year and now it's making you uncomfortable. You also say that you do not have the 
money to pay out-of-pocket for this procedure. The Plan denied your request. The Plan says these services are 
not covered under the benefit package.  
 
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 the 
abutment supported porcelain fused to metal crown tooth #19 (high noble metal) (D6059), custom fabricated 
abutment - includes placement tooth #19 (D6057), and surgical placement of implant body: endosteal implant 
tooth #19 (D6010).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92613 for date of service  
 
You asked the Plan to pay for procedure code 92613. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the code billed 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 92613 is flexible endoscopic evaluation of swallowing by 
cine or video recording; interpretation and report only. 
 
We find that CPT code 92613 is not supported in the medical record. Specifically, the submitted medical 
records do not support that flexible endoscopic evaluation of swallowing by cine or video recording; 
interpretation and report only was performed. Based on this information, we decided that Medicare rules for 
coverage of procedure code 92613 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 92613 for date of service
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 18, 
2022. 
 
You asked the Plan to pay for D0140. You say that you were told this provider was in-network. The Plan 
denied your request. The Plan says D0140 is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140) provided on August 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the standard rigid side guards (K0108). 
 
You asked the Plan to pre-approve the side guards. You say that say the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the side guards are not 
considered to be primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the standard rigid side guards (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94760 billed for date of service August 15, 
2022. 
 
You asked the Plan to pay for procedure code 94760. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says procedure code 94760 is bundled and not separately 
payable in this case. 
 
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 94760 has a status indicator of T on the Physician Fee Schedule. The case record 
supports that another payable service was billed on the same date by the same provider. This means that 
procedure code 94760 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 94760 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 94760 billed for date of service August 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75726 billed for date of service September 5, 
2022. 
 
You asked the Plan to pay for procedure code 75726-26-XU. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says payment for code 75726-26-XU is bundled into 
payment for code 37244. 
 
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 75726 
is a column II code to column I code 37244. 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 75726 billed for date of service September 5, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on March 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
comprehensive periodontal evaluation (D0180) provided on March 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 4, 2021, billed with 
codes 81273, 81270, 81339, 81279 and 81219. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical records. 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 
August 4, 2021, billed with codes 81273, 81270, 81339, 81279 and 81219.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic parenteral drug (D9610) provided on February 
14, 2023. 
 
You asked the Plan to pay for therapeutic parenteral drug. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
therapeutic parenteral drug (D9610) provided on February 14, 2023.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from July 6, 2022, to 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 the claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that if the entire facility qualifies as a Medicare-certified SNF, all Part B services rendered to residents are billed on Type of Bill (TOB) 22x

We looked at the file and Medicare rules. The file shows that the claim was not billed with the required TOB 22x. 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 the skilled nursing facility (SNF) services rendered from July 6, 2022, to July 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hemoglobin; glycosylated (A1c)) (83036) rheumatoid factor 
(86431) sedimentation rate, erythrocyte (85652) provided January 19, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that please see medical records. Please review 
and reprocess. The Plan denied your request. The Plan says these services are not a Medicare benefit for the 
diagnoses listed and are done for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for hemoglobin; glycosylated (A1c)) (83036) rheumatoid factor (86431) sedimentation rate, erythrocyte 
(85652) provided January 19, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97112 billed for date of service January 30, 
2023, to February 1, 2023. 
 
You asked the Plan to pay for procedure code 97112. The Plan denied your request. The Plan says payment for 
code 97112 is bundled into payment for code 95992. 
 
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 97112 is a column II code to column I code 95992. Code 97112 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 97112 
billed for date of service January 30, 2023, to February 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service December 4, 
2022. 
 
You asked the Plan to pay for procedure code 99233. You say that you have billed the service 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 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 care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 
We find that CPT code 99233 is not supported in the medical record. Specifically, records for date of service 
December 4, 2022, were not provided. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99233 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99233 billed for date of service December 4, 2022.