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

 
We decided that the Plan does not have to pay for procedure codes 77067 and 77063 billed for February 23, 
2023. 
 
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 with the wrong place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The file shows that the claim was billed with POS code 23 for an 
emergency room; however, the type of bill (TOB) was billed as 131 for an outpatient hospital department. The 
POS code does not match the billed TOB. Therefore, we decided that the Plan does not have to pay for 
procedure codes 77067 and 77063 billed for February 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 82 units of code 01402 and 1 unit of 64447-59 billed for date 
of service January 31, 2023. 
 
You asked the Plan to pay for 82 units of code 01402 and 1 unit of 64447-59. You say that these services were 
billed correctly. The Plan denied your request. The Plan says these services are not supported in the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure 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 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 82 units of code 01402 and 1 unit of 64447-
59 Our reviewer says that the billed codes are not supported in the records. Our physician reviewer found 
although the records document 82 minutes of anesthesia time, each unit of code 01402 represents a 15-minute 
increment of anesthesia time, meaning 82 units of 01402 are not supported. The documentation also does not 
support the injection billed with 64447-59 was a distinct procedural service from the anesthesia service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 82 units of code 01402 and 1 unit of 64447-59 have not been met. Therefore, 
we decided that the Plan does not have to pay for 82 units of code 01402 and 1 unit of 64447-59 billed for date 
of service January 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 87900 billed for date of service October 10, 2022. 
 
You asked the Plan to pay for code 87900. You say that this should be covered. 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 87900 is infectious agent drug susceptibility phenotype 
prediction using regularly updated genotypic bioinformatics. 
 
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 code 87900. Our reviewer says that this code is not supported 
in the records. Our reviewer found the procedure report does not include quantitative prediction of drug 
susceptibility phenotype  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 87900 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 87900 billed for date of service October 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 10, 2023 to January 31, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
10, 2023 to January 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and core buildup (D2950) for tooth #14 
provided on May 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider never told you that the dental 
services would not be covered, and you should not be liable for the denied amount. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the crown and core buildup 
are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 crown 
(D2740) and core buildup (D2950) for tooth #14 provided on May 3, 2023.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve home health services. 
 
You asked the Plan to pre-approve the home health services. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide the medical records used in making their 
determination. The Plan has failed to substantiate the denial for the requested home health services. Therefore, 
we decided that the Plan has to pre-approve home health services.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the records provided support medical necessity. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the member was not noted to meet 
diagnostic criteria for either let alone both AD and FTD. The member is also noted to have at least one other 
potential cause for their dementia (vascular). In such a setting the base requirement of the NCD would not have 
been met. 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral complete series of radiographic images (D0210) 
provided on April 26, 2023. 
 
You asked the Plan to pay for the dental service. You say that the previous provider used up all your x-ray 
benefits and you would like the Plan to cover the dental x-ray. The Plan denied your request. The Plan says 
your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 for the intraoral complete series of radiographic images (D0210) on February 21, 2023; 
therefore, your benefit for the requested item or service was exhausted on the date of service of February 21, 
2023. Therefore, we decided that the Plan does not have to pay for the intraoral complete series of radiographic 
images (D0210) provided on April 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 3 sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre 3 sensor. You say that you were better when you had the 
Freestyle Libre 3 sensor as you had much better control. The Plan denied your request. The Plan says you do 
not meet the criteria for the CGM. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 FreeStyle Libre 3 sensor. Our 
reviewer says that the FreeStyle Libre 3 sensor is not medically necessary. Our physician reviewer found 
coverage criteria require low blood glucose sugar to the point of being below 54 and persistent despite 
adjustments in medications. There is no mention of how low and how frequent/persistent your blood glucose 
sugars are. You are not on insulin, and it is unlikely your medications are leading to low blood glucose sugar. 
With the current data provided, criteria for CGM are not met. 
 
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 FreeStyle Libre 3 sensor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a FreeStyle Libre 3 sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided by a chiropractor on June 1, 2023. 
 
You asked the Plan to pay for the office visit. You say that you have been to the hospital numerous times, have 
tried nerve blocks for your headaches and were told that going to a chiropractor may help. The Plan denied 
your request. The Plan says that an office visit is not a covered benefit when billed by a chiropractor. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit provided by a chiropractor on June 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional payment for the clinical crown lengthening-hard 
tissue (D4249) provided on April 25, 2023.  
 
You asked the Plan to issue additional payment for the dental service. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says your benefit for 
the service provided 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 your benefit for the service provided has been exhausted.   
 
 
 
 
Specifically, the Plans contract states that your maximum allowable benefit per year is $500. The Plan issued 
payment in the amount of $500 ($129 + $73.35 + $297.65) for dental services provided for the 2023 calendar 
year. Therefore, you have exhausted the benefit for the service provided in this case. Therefore, we decided that 
the Plan does not have to issue additional payment for the clinical crown lengthening-hard tissue (D4249) 
provided on April 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95937 billed for date of service April 26, 
2023. 
 
You asked the Plan to pay for procedure code 95937. 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; it is inappropriate to use this code for train-of-four testing, which is automatically included in other 
services provided and is not separately reportable. 
 
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. 
 
 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 represented in the records provided. Our reviewer found the procedure report does not include 
documentation of neuromuscular junction testing. The provider performed train of four (T04) testing, which is 
incorrect to report as neuromuscular junction testing, as T04 testing does not have an assigned CPT code. T04 
is inclusive to the primary neuromonitoring service and is not separately reported. 
 
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 April 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #13 provided on April 17, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you were surprised that the Plan covers crowns 
but does not cover core buildup. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the core buildup is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup (D2950) for tooth #13 provided on April 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 93229 and 93228 billed for date of service March 27, 
2023. 
 
You asked the Plan to pay for codes 93229 and 93228. You say that the medical records support payment for 
these codes. The Plan denied your request. The Plan says codes 93229 and 93228 are not supported by the 
medical record because there is no physician order. 
 
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 93229 is External mobile cardiovascular telemetry with 
electrocardiographic recording, concurrent computerized real-time data analysis, and greater than 24 hours of 
accessible ECG data storage (retrievable with query) with ECG-triggered and patient-selected events 
transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports 
as prescribed by a physician or other qualified healthcare professional. Th definition of code 93228 is External 
mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data 
analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered 
and patient selected events transmitted to a remote attended surveillance center for up to 30 days; review and 
interpretation with report by a physician or other qualified health care professional. 
 
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 codes 93229 and 93228. Our reviewer says that codes 93229 
and 93228 are not supported by the medical record. Our reviewer found neither of these procedure codes 
include a physician order to verify services. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 93229 and 93228 have not been met. Therefore, we decided that the Plan 
does not have to pay for codes 93229 and 93228 billed for date of service March 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99152 billed for date of service April 20, 2023. 
 
You asked the Plan to pay for code 99152. You say that the medical records support the billing of this code, as 
the record shows both the start and stop times. The Plan denied your request. The Plan says code 99152 is not 
supported by the medical record. The submitted the medical records don't indicate the intra-service time for 
moderate sedation services. 
 
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 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. 
 
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 code 99152. Our reviewer says that code 99152 is not 
supported by the medical record. Our reviewer found there was documentation that Versed and Fentanyl were 
administered, however, there was no anesthesiology record documenting intraoperative/intra-procedural 
monitoring of this patient (including continuous monitoring of blood pressure, heart rate, respiratory rate, EKG, 
oxygen saturation).  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99152 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99152 billed for date of service April 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 6, 2023. 
 
You asked the Plan to pay for the lab services. You say that due to the pandemic, submitting information timely 
for this claim has been difficult. The Plan denied your request. The Plan says two of the billed diagnosis codes 
cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that Z03.818 has an Excludes1 note in relation to Z01.812. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the lab services have not been met. Therefore, we decided that the Plan does not have to pay 
for lab services provided on January 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and an extraction (D7210) 
for tooth #19 provided on June 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were advised that you needed to get teeth 
extracted to remove an infection. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because the limited oral evaluation and the extraction are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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) and an extraction (D7210) for tooth #19 provided on June 12, 2023.