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

 
We decided that the Plan does not have to pre-approve Helicoll and Celera. 
 
You asked the Plan to pre-approve Helicoll and Celera. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that application of a skin substitute graft for lower 
extremity DFU and VLU will be covered when certain conditions are met and documented as appropriate for 
the individual patient. 
 
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 Helicoll and Celera. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the skin treatments, Helicoll, 
PalinGen, and Celera were requested, however, only PalinGen was approved. Only one graft product/procedure 
per wound per 12 weeks is reasonable. There was no documentation explaining why this case was an exception 
requiring multiple grafting products at the same time to help justify this request. Therefore, this request for 
Helicoll and Celera does not meet the LCD criteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Helicoll and Celera have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Helicoll and Celera.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95870 and 95940 for date of service June 
21, 2023. 
 
You asked the Plan to pay for procedure codes 95870 and 95940. 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 95870 and 95940 are not supported in the medical record. Specifically, the 
documentation does not include that needle electromyography; limited study of muscles in 1 extremity or non-
limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or 
sphincters was performed. Therefore, code 95870 cannot be verified. The documentation does include a 
procedure note; however, the records did not include that continuous intraoperative neurophysiology 
monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes was 
performed. Therefore, code 95940 cannot be verified. Based on this information, we decided that Medicare 
rules for coverage of procedure codes 95870 and 95940 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 95870 and 95940 for date of service June 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services and the office visit provided on 
June 6, 2023. 
 
You asked the Plan to pay for  the office visit. You say that you have loss of sensation and muscle weakness. 
You say that your pain impacts your daily living, and the acupuncture services has helped ease the pain. The 
Plan denied your request. The Plan says that acupuncture is only covered for chronic low back pain. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, acupuncture is only covered for chronic low back 
pain. Therefore, we decided that the Plan does not have to pay for  the acupuncture services and the office visit 
provided on June 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve modification of removable prosthesis following implant 
surgery (D5875). 
 
You asked the Plan to pre-approve modification of removable prosthesis following implant surgery.. You say 
that this is medically necessary. 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 pre-approve 
modification of removable prosthesis following implant surgery (D5875).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87491 billed for date of service June 23, 
2023. 
 
You asked the Plan to pay for procedure code 87491. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says this code 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 87491 is infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified 
probe technique. 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 87491. Our reviewer says that the 
documentation provided does not support code 87491. Our reviewer found the note and lab orders do not 
support this code, as the notes and order support urinary analysis for a urinary tract infection. 
 
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 87491 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87491 billed for date of service June 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) for tooth #26 provided on April 27, 
2023. 
 
You asked the Plan to pay more for the dental service. You say that the dental services were medically 
necessary. The Plan denied your request. The Plan says your maximum dental 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 Plans 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 $797 for dental services on January 17, 2023. On April 27, 2023, the Plan paid $1,203 for 
dental services. For the year of 2023 the Plan paid $2,000 ($797 paid + $1,203 paid) for dental services, 
therefore, your annual dental maximum benefit for the year of 2023 was exhausted on the date of service of 
April 27, 2023. Therefore, we decided that the Plan does not have to pay more for a crown (D2740) for tooth 
#26 provided on April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits (99213) provided from June 15, 2023, 
through June 26, 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 the services provided are not a covered 
benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
 
  
 
 
 
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visits (99213) provided from June 15, 2023, through June 26, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service April 21, 
2023. 
 
You asked the Plan to pay for procedure code 87640. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 87640 is bundled into payment for code 87641. 
 
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. In this 
case, we have confirmed that code 87640 is a column II code to column I code 87641. While code 87640 was 
billed with modifier -59, the medical records provided do not show that the service billed with the -59 modifier 
is a distinct procedural service. 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 87640 billed for date of service 
April 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel provided March 27, 2023, billed with 
codes 87150-90-XU, 87481-90-XU, 87641-90-XU, 87653-90-XU, 87798-90-XU x12, 87801-90 x3.  

You asked the Plan to pay for the laboratory testing. You say that kindly review the attached documents and 
process this claim towards possible payment. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT 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 laboratory testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the Urine PCR panel provided 
March 27, 2023, billed with codes 87150-90-XU, 87481-90-XU, 87641-90-XU, 87653-90-XU, 87798-90-XU 
x12, 87801-90 x3.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each renal dialysis service provided on 
March 31, 2023, to July 03, 2023. 
 
You asked the Plan to waive the coinsurance for each renal dialysis service. You say that you want to appeal 
the amount being charged. 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 contract with the Plan clearly says that you must pay 20% 
coinsurance for services to treat kidney disease. 
 
You have been asked to pay 20% coinsurance for each renal dialysis service. This item/service falls within the 
services to treat kidney disease 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. The total you owe is $960 ($300 allowed amount x 20% = $60) [$60 copayment 
x 16 visits = $960]). Therefore, we decided that the Plan does not have to waive the coinsurance for each renal 
dialysis service provided on March 31, 2023, to July 03, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a microprocessor knee (L5828, L5845, L5848, L5856). 
 
You asked the Plan to pre-approve a microprocessor knee. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that a lower limb prosthesis 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 a microprocessor knee. Our reviewer says that the services are medically necessary. Our physician reviewer found the medical record (e.g. the CPO 
and prescriber notes from September) go above and beyond in satisfying Medicare policy by demonstrating this 
enrollee has K3 functional level potential and has specific needs for the requested components. In the case of 
this enrollee, and all comparable K3 ambulators, lesser devices simply would not meet his functional needs and 
would amount to substandard care. 
 
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 microprocessor knee have been met. Therefore, we decided that the Plan has 
to pre-approve a microprocessor knee (L5828, L5845, L5848, L5856).  
 
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 laboratory services (procedure code 0295U) rendered on 
June 8, 2023. 
 
You asked the Plan to pay for the services. You say that the services were time-sensitive and medically necessary The Plan denied your request. The Plan says the 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 0295U is "Oncology (breast ductal carcinoma in situ), 
protein expression profiling by immunohistochemistry of 7 proteins (COX2, FOXA1, HER2, Ki-67, p16, PR, 
SIAH2), with 4 clinicopathologic factors (size, age, margin status, palpability), utilizing formalin-fixed 
paraffin-embedded (FFPE) tissue, algorithm reported as a recurrence risk score." 
 
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 not supported by the medical records. Our reviewer found that the laboratory report does not include documentation of 7 proteins per CPT code description, and therefore 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (procedure code 0295U) rendered on June 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab code 87150 provided on November 5, 2022. 
 
You asked the Plan to pay for 87150. You say that this code is correct and valid. The Plan denied your request. 
The Plan says this 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 87150 is culture, typing; identification by nucleic acid 
probe, amplified probe technique, per culture or isolate, each organism probed for service provided. 
 
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 87150. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found the laboratory report does not include sufficient documentation to 
support that this lab testing was performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87150 have not been met. Therefore, we decided that the Plan does not have to 
pay for lab code 87150 provided on November 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 19, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel provided April 6, 2023, billed with 
codes 87150-90-XU, 87481-90-XU, 87798-90-XU. 
 
You asked the Plan to pay for the laboratory testing. You say that kindly review the attached documents and 
process this claim towards possible payment. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the Urine PCR panel provided April 
6, 2023, billed with codes 87150-90-XU, 87481-90-XU, 87798-90-XU.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) billed with procedure 
code G0482 provided on March 17, 2023. 
 
You asked the Plan to pay for procedure code G0482. You say that the definitive UDT testing (G0482) was 
medically necessary.  The Plan denied your request. The Plan says the definitive UDT testing (G0482) was 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 pay for procedure code G0482. Our reviewer says 
that the definitive UDT testing (G0482) was not medically necessary. Our physician reviewer found the 
number of definitive urine drug classes tested was not medically necessary and the enrollee did not meet the 
stated LCD criteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code G0482 have not been met. Therefore, we decided that the Plan 
does not have to pay for the definitive urine drug testing (UDT) billed with procedure code G0482 provided on 
March 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95937 and 95861 for date of service May 
23, 2023. 
 
You asked the Plan to pay for procedure codes 95937 and 95861. 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. 
 
In this case, the CPT Code Manual definition of code 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method.  The CPT Code Manual definition of code 95861 is needle electromyography; 2 extremities with or without 
related paraspinal areas. 
 
We find that CPT codes 95937 and 95861 are not supported in the medical record. Specifically, the medical 
records submitted indicate that train of four testing was performed. Current Procedural Terminology (CPT) 
code 95937, neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any one method 
was billed. Train of four testing does not fit the criteria for this code as it is inappropriate to bill the code for 
neuromuscular junction when train of four monitoring is performed. This means code 95937 is not supported. 
The submitted medical records include report of needle electromyography; 2 extremities with or without 
related paraspinal areas was performed however do not include that the sub dermal needle, needle/electrode 
were inserted into muscle. Therefore, code 95861 cannot be verified. Based on this information, we decided 
that Medicare rules for coverage of procedure codes 95937 and 95861 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 95937 and 95861 for date of service May 23, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted surgical navigation for right total 
shoulder arthroplasty. 
 
You asked the Plan to pre-approve computer-assisted surgical navigation. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the clinical value and effectiveness of 
computer-assisted surgical navigation in joint replacement surgery have not been established. 
 
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 computer-assisted surgical navigation. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no large volume, long-term, high-quality clinical studies that 
confirm the clinical benefits of computer-assisted surgery over standard surgical approaches in total shoulder 
arthroplasty. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computer-assisted surgical navigation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve computer-assisted surgical navigation for right total shoulder 
arthroplasty.