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

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641 and 87653 billed for 
date of service December 30, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641 and 87653. You say that these services 
were reported appropriately and are supported in the medical record. The Plan denied your request. The Plan 
says these services are not supported for separate payment 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 CPT code. 
 
In this case, we have confirmed that codes 87150, 87481, 87641 and 87653 are column II codes to column I 
codes 87500, 87801 and/or 87150. Code 87481 has not been billed with an appropriate modifier to bypass the 
edit. Based on the claim submitted, Medicare billing criteria have not been met for code 87481. However, 
procedure codes 87150, 87641 and 87653 were each 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 codes 87150, 87641 and 87653. Our reviewer says 
that these services are not supported for separate reporting. Our reviewer found there is no documentation that 
support the use of the XU modifier with codes 87150, 87641 and 87653. Provided records in this case do not 
document that the services in question were distinct or separate from other services billed and reimbursed 
(87500 and 87801).  
 
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 87150, 87481, 87641 and 87653 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641 and 87653 billed for 
date of service December 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
November 29, 2022. 
 
You asked the Plan to pay for procedure codes 87481 and 87653. You say that this testing should be 
reimbursed.  The Plan denied your request. The Plan says payment for codes 87481 and 87653 is bundled into 
payment for code 87801. 
 
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 and 87653 are column II codes to column I code 87801.  
 
Though the column II codes were billed with modifier -XU, the documentation does not support these tests 
were distinct from the testing described by 87801. 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 87481 and 87653 
billed for date of service November 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 billed for date of service January 4, 
2023. 
 
You asked the Plan to pay for procedure code 87481. You say that you have submitted medical records to 
support payment. The Plan denied your request. The Plan says payment for code 87481 is bundled into 
payment for code 87801. 
 
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 87481 
is a column II code to column I code 87801. 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 87481 billed for date of service January 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left radiofrequency endovenous ablation.  
 
You asked the Plan to pre-approve left radiofrequency endovenous ablation. You say that the requested left 
radiofrequency endovenous ablation is medically necessary. The Plan denied your request. The Plan says the 
requested left radiofrequency endovenous ablation does not meet the Medicare LCD coverage criteria.  
 
The Plan follows Medicare rules. 
 
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 left radiofrequency endovenous 
ablation. Our reviewer says that the requested left radiofrequency endovenous ablation is not considered 
medically necessary in this case. Our physician reviewer found that there is inadequate documentation that the 
enrollee is having lifestyle limiting pain. Additionally, it is not possible to attribute any lower extremity 
symptoms to the enrollee's veins without an assessment of arterial perfusion particularly in this enrollee taking 
antidiabetic medication. It is documented that the enrollee is asymptomatic when using compression 
stockings. Therefore, it does not appear that the enrollee is failing conservative treatment. Given inadequate 
documentation of symptom severity, apparent response to conservative treatment, and unclear status with 
respect to lower extremity arterial perfusion, the enrollee does not meet the Medicare coverage 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 left radiofrequency endovenous ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve left radiofrequency endovenous ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95955, 95938, and 95937 provided on July 
19, 2022. 
 
You asked the Plan to pay for procedure codes 95955, 95938, and 95937. You say that the medical records 
support the billing of codes 95955, 95938, and 95937.  The Plan denied your request. The Plan says the 
medical records do not support the billing of codes 95955, 95938, and 95937.  
 
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 95955 is Electroencephalogram (EEG) during 
nonintracranial surgery (eg, carotid surgery). The definition of code 95938 is Short-latency somatosensory 
evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous 
system; in upper and lower limbs. The 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 codes 95955, 95938, and 95937. Our reviewer 
says that the medical records do not support the billing of codes 95955, 95938, and 95937.  Our reviewer found 
procedure code 95955 is not supported. The record states that the EEG was performed as intraoperative 
neuromonitoring only, there is no separate interpretation and report that would support a diagnostic EEG 
during non-intracranial surgery. 
 
Procedure code 95937 is not supported. The record states that this code was reported for train of four testing. 
According to CPT rules, train of four testing is a component of intraoperative neuromonitoring and cannot be 
reported separately with 95937. 
 
Procedure code 95938 is not supported. Although the report mentions that latency and velocity are performed 
as part of the intraoperative neuromonitoring, there is no documentation in the record supporting that this was 
performed. The record also does not specify where the stimulation 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 procedure codes 95955, 95938, and 95937 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 95955, 95938, and 95937 provided on July 19, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service November 
29, 2022. 
 
You asked the Plan to pay for procedure code 81345. You say that the testing should be covered.  The Plan 
denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service November 29, 
2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed for date of service November 2, 2022.

You asked the Plan to pay for procedure codes 87481, 87653 and 87798. You say that these services were necessary and are supported as billed. The Plan denied your request. The Plan says the payment for these codes is included in the payment for code 87801. Although these services were reported with a modifier, the records do not support that this modifier was used correctly.

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; however, 87481, 87653 and 87798 were 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 codes 87481, 87653 and 87798. Our reviewer says that these services are not supported for separate billing/reporting. Our reviewer found the XU modifier is a modifier that stands for "Unusual Non-Overlapping Service". It is used to indicate that a service is distinct because it does not overlap usual components of the main service. Provided records in this case do not support the billed services were distinct with no overlap with the usual components of the main service.

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 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed for date of service November 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed for date of 
service November 2, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653 and 87798. You say that these services were 
necessary and are supported as billed. The Plan denied your request. The Plan says the payment for these codes 
is included in the payment for code 87801. Although these services were reported with a modifier, the records 
do not support that this modifier was used correctly. 
 
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; however, 87481, 87653 and 87798 were 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 codes 87481, 87653 and 87798. Our reviewer says 
that these services are not supported for separate billing/reporting. Our reviewer found the XU modifier is a 
modifier that stands for "Unusual Non-Overlapping Service". It is used to indicate that a service is distinct 
because it does not overlap usual components of the main service. Provided records in this case do not support 
the billed services were distinct with no overlap with the usual components of the main service. 
 
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 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed for date of 
service November 2, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for dates of service January 11, 
2023, to January 16, 2023. 
 
You asked the Plan to pay for procedure code 97010. You say that this should be paid. The Plan denied your 
request. The Plan says procedure code 97010 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 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for dates of service January 11, 2023, to January 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup for tooth #9 
 
You asked the Plan to pre-approve core buildup. You say that this is medically necessary. The Plan denied your 
request. The Plan says core buildup is covered when there is extensive loss of tooth structure as evidenced by 
radiographic images or narrative report, or when need is suggested by dental history such as following root 
canal treatment. Review of the member's records show that tooth #9 did not meet these criteria for coverage of 
the core build up. 
 
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. The Plan covers core buildup 
when the services are medically necessary and reasonable.   
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 core buildup. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found a review of the documentation indicates that 
tooth #9 does not appear to have significant coronal breakdown to warrant a core buildup procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of core buildup have not been met. Therefore, we decided that the Plan does not 
have to pre-approve core buildup for tooth #9
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81404, 81405) provided on February 17, 
2022. 
 
You asked the Plan to pay for genetic testing. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says with the information they have, the Plan cannot 
determine how the enrollee came to the servicing provider, or whether the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. We cannot determine how the enrollee came to the servicing provider 
or whether the services are medically necessary. After three or more attempts to obtain information, none was 
received. Based on this information, we decided that there is insufficient information in the record to determine 
if Medicare rules for coverage of genetic testing have been met. . Therefore, we decided that the Plan does not 
have to pay for genetic testing (81404, 81405) provided on February 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 84480 billed for date of service December 
12, 2022.   

You asked the Plan to pay for procedure code 84480. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 84480 is bundled into 
payment for code 84481. 
 
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 84480 
is a column II code to column I code 84481 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 84480 billed for date of service December 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87653 and 87481 billed for date of service 
October 10, 2022. 
 
You asked the Plan to pay for procedure codes 87653 and 87481. You say that these services are supported in 
the medical record. The Plan denied your request. The Plan says payment for codes 87653 and 87481 is 
bundled into payment for code 87801. 
 
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 
87653 and 87481 are column II codes to column I code 87801. These services have 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 87653 and 87481 billed for 
date of service October 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you do not agree with the denial of the 
removable foot inserts. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy (36471). 
 
You asked the Plan to pre-approve sclerotherapy. You say that these services are medically necessary and 
appropriate for this enrollee. The Plan denied your request. The Plan says the enrollee does not meet coverage 
criteria for sclerotherapy as saphenous reflux is present and veins are less than 4mm. However, the Plan has 
approved the requested great saphenous vein (GSV) ablation. 

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 sclerotherapy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found for tributary treatment such sclerotherapy to be considered medically necessary per coverage 
criteria, there needs to be persistent significant symptoms following successful treatment of truncal (saphenous) 
reflux with these symptoms existing more than 6 weeks after the reflux was treated and despite conservative 
efforts. Additionally, the veins to be treated need to be at least 4 mm in diameter. This condition has not been 
met as varicosities are documented to be less than 4 mm in diameter. As the enrollee has not yet undergone 
saphenous vein reflux treatment, the above criteria have not been met. In addition, the health plan does not 
provide for simultaneous saphenous reflux treatment and tributary treatment. A rationale for this is that many 
patients experience satisfactory relief with the truncal intervention alone. Furthermore, criteria require that the 
patient's symptoms be attributable to the veins to be treated. It is not possible to attribute the patient's 
symptoms to varicose veins without assessment of arterial perfusion to the lower extremities. Overall, criteria 
are not met, and the documentation does not support the medical necessity of the treatments in question. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sclerotherapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sclerotherapy (36471).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve plastic low side guard, quickie backpack, and seat 
pouch. 
 
You asked the Plan to pre-approve plastic low side guard, quickie backpack, and seat pouch. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested items are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 
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 plastic low side guard, quickie backpack, and seat pouch.