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

 
We decided that the Plan does not have to pay for procedure codes 94761 and 99072 billed for date of service 
April 14, 2022.  
 
You asked the Plan to pay for procedure codes 94761 and 99072. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says payment for code 94761 is bundled 
into payment for code 94618. The Plan also says that code 99072 is 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 CPT code. In this case, we have confirmed that code 94761 
is a column II code to column I code 94618 with a modifier indicator of 0. The column II code is therefore not 
payable.  
 
Medicare rules also say that the Physician Fee Schedule Status Indicator B means that payment for covered 
services is always bundled into payment for other services not specified. There will be no payment amounts for 
these codes and no separate payment is ever made. In this case, code 99072 has a status indicator of B, so no 
separate payment can be made for this code. 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 94761 and 99072 billed 
for date of service April 14, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code U0005 billed for date of service February 7, 2022. We 
decided that the Plan does not have to pay for procedure code U0005 billed for date of service January 24, 
2022.  
 
You asked the Plan to pay for the lab testing billed for dates of service January 24, 2022, to February 7, 2022.. 
You say that the codes are payable. The Plan says that the services were included in the skilled nursing claim. 
 
We decided that the Plan has to pay for procedure code U0005 billed for date of service February 7, 
2022.  
 
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 the rules. The claim information provided does not show that the enrollee was in a 
covered SNF stay on February 7, 2022. The claims show that covered SNF services were provided from 
February 10-12, 2022. We have also confirmed that code U0005 is an add-on code that has been billed with an 
appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan has to pay for procedure code U0005 billed for date of service February 7, 
2022.  
 
We also decided that the Plan does not have to pay for procedure code U0005 billed for date of service 
January 24, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The file shows that the enrollee was in a covered SNF stay at the time the 
services were provided. Based on this information, we decided that the Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code U0005 billed for date of 
service January 24, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that kyphoplasty 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not clearly document 
failure of non-surgical management for this enrollee. No specific pain medications are prescribed for the L3 
compression fracture. Furthermore, the imaging shows retropulsion of the superior endplate of L3, which is a 
relative contraindication for kyphoplasty. The criteria for coverage are not met and the services are not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve kyphoplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested bone marrow aspirate is 
experimental in nature, as more research is needed to support its use. The services are therefore not reasonable 
or medically necessary at this time.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T8-T9 kyphoplasty 
 
You asked the Plan to pre-approve kyphoplasty surgery. You say that the enrollee is at 10/10 pain. The Plan 
denied your request. The Plan says the enrollee's pain is multifactorial with multilevel disc disease. 
 
The Plan follows Medicare rules. Medicare rules state that kyphoplasty surgery may be covered if certain 
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 kyphoplasty surgery. Our reviewer says 
that the enrollee does not meet criteria for this procedure. Our physician reviewer found detailed 
documentation is not consistently evident regarding an acute or subacute compression fracture. Thoracic 
magnetic resonance imaging (MRI) stated "chronic appearing" mild anterior wedge deformities at T6, T7, T8, 
and T9 per the radiologist. There is no indication of a progression of the body height loss or a severe impact on 
daily activities. Moreover, there is MRI corroboration of other plausible causes of pain. Therefore, the enrollee 
does not meet criteria for this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve T8-T9 kyphoplasty
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95999 billed for date of service July 8, 2022. 
 
You asked the Plan to pay for the billed code. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the service was a component part of the comprehensive code. 
 
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 95999 was billed to identify train of four testing. Train of four testing is bundled with 
the intraoperative neuromonitoring. Based on this information, we decided that Medicare rules for coverage of 
the billed code have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
95999 billed for date of service July 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pontics (D6242) provided on March 15, 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 pontics 
(D6242) provided on March 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
when three or more power seating functions/actuators/motors are provided, one unit of E2311, one unit of 
E2377, and one unit of E2313 are allowed. The Plan denied your request. The Plan says although there are 
three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical 
need to control these power options through the joystick.  
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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has sufficient strength and 
function in upper extremities to manage standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2311, E2313). 
 
You asked the Plan to pre-approve an expandable controller. You say that these items are medically necessary. 
The Plan denied your request. The Plan says the enrollee can control the approved power options with their 
own switches. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that expandable controllers are covered when necessary for a 
function listed 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 an expandable controller. Our reviewer 
says that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the submitted records document that the enrollee is independent with feeding and grooming, 
indicating she has adequate upper extremity strength and function to operate the wheelchairs power options 
with their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable controller (E2377, E2311, E2313).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (PWC) with multiple power options 
(K0861). 
 
You asked the Plan to pre-approve a power wheelchair with multiple power options. You say that the item is 
medically necessary. The Plan denied your request. The Plan says documentation shows that you are not at 
"High Risk" for skin breakdown; has been using a manual wheelchair at home and has no current pressure 
ulcer, no history of pressure ulcer or flap surgery, no self-catheterization or spasticity and you have normal tone 
and is on no anti-spasmodics. 
 
The Plan follows Medicare rules. Medicare rules say a group 3 PWC with multiple power options is covered if 
all the criteria listed in the Medicare Rules section is 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 power wheelchair with multiple 
power options. Our reviewer says that the item is not medically necessary. Our physician reviewer found the 
documentation does not support that you are at high risk for development of a pressure ulcer, utilizes 
intermittent catheterization for bladder management, or needs a power seating system to manage increased tone 
or spasticity. You have no current or prior history of pressure ulcers and you do not use a ventilator mounted to 
a wheelchair.  
 
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 power wheelchair with multiple power options have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (PWC) with multiple power options 
(K0861).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with two or more power 
seat options and accessories (E0955, E1007, E1012, E1028, E2311, E2313, E2361, E2377, K0861).  
You asked the Plan to pre-approve a group 3 power wheelchair with two or more power seat options and 
accessories. 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 follows Medicare rules. Medicare rules say that power mobility devices are 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 group 3 power wheelchair with two or 
more power seat options and accessories. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the enrollee does not require a ventilator or power tilt and recline seating therefore 
Group 3 K0861 Power Wheelchair with multiple power options and related requested accessories are not 
medically necessary. 
 
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 group 3 power wheelchair with two or more power seat options and 
accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 
power wheelchair with two or more power seat options and accessories (E0955, E1007, E1012, E1028, E2311, 
E2313, E2361, E2377, K0861).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, electronic connection 
device, Linx joystick, and custom straight backpost for a power wheelchair. 
 
You asked the Plan to pre-approve expandable controller, harness, electronic connection device, joystick, and 
backpost. You say that you need these components. The Plan denied your request. The Plan says these are 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 pre-approve expandable controller, harness, 
electronic connection device, joystick, and backpost. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found you have 
sufficient strength and function in your upper extremities to manage standard power drives. For power 
wheelchairs, there is no separate billing for non-standard seat frame dimensions. The back support is not a 
billable separate accessory. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of expandable controller, harness, electronic connection device, joystick, and 
backpost have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable 
controller, harness, electronic connection device, Linx joystick, and custom straight backpost for a power 
wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, and 87798 
billed for date of service February 10, 2023. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, and 87798. You say that medical 
records were submitted. The Plan denied your request. The Plan says payment for codes 87150, 87481, 87641, 
87653, and 87798 are bundled into payment for codes 87801 and 87500. 
 
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 87150 is a column II code to column I code 87500. We have also 
confirmed that codes 87481, 87641, 87653, and 87798 are column II codes to column I code 87801. The claim 
shows that codes 87150, 87481, 87641, 87653, and 87798 were billed with the XU modifier. The records do 
not show that the billed codes were unusual non-overlapping components of the main 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 codes 87150, 87481, 87641, 87653, and 87798 billed for date of service February 10, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81295, 81297-59, 81298, and 81317 billed 
for date of service December 1, 2022. 
 
You asked the Plan to pay for procedure codes 81295, 81297, 81298, and 81317. You say that this testing was 
billed correctly. 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 81295 is MSH2 (mutS homolog 2, colon cancer, 
nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full 
sequence analysis. The definition of 81297 is MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, 
hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants. The 
definition of 81298 is MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, 
Lynch syndrome) gene analysis; full sequence analysis. The definition of 81317 is PMS2 (postmeiotic 
segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene 
analysis; full sequence analysis. 
 
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 81295, 81297, 81298, and 81317. Our 
reviewer says that these codes are not supported. Our reviewer found the submitted laboratory report 
documents MSH2, MSH6, and PMS2 with result "uncertain clinical significance." The evaluation and 
management report documents "Germline mutation testing" which would not be coded with codes 81295, 
81297, 81298, and 81317. 
 
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 81295, 81297, 81298, and 81317 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 81295, 81297-59, 81298, and 
81317 billed for date of service December 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010), the 
custom fabricated abutment (D6057), and the abutment supported to crown (D6058) for tooth #21 and #28. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says your benefit for the requested items or services 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 Plan pre-approved the surgical placement of implant body (D6010), the custom fabricated abutment 
(D6057), and the abutment supported to crown (D6058) for tooth #22 and #27 on August 10, 2023; therefore, 
your benefit for the requested items or services was exhausted on the date of approval of August 10, 2023. 
Therefore, we decided that the Plan does not have to pre-approve the surgical placement of implant body 
(D6010), the custom fabricated abutment (D6057), and the abutment supported to crown (D6058) for tooth #21 
and #28.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an apicoectomy (D3410) for tooth #8 and anesthesia 
(D9222 and D9223). 
 
You asked the Plan to pre-approve the dental services. You say that you are getting extractions and the dental 
services are medically necessary. The Plan denied your request. The Plan says the denial of authorization for 
these services is correct, because the apicoectomy and anesthesia 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
apicoectomy (D3410) for tooth #8 and anesthesia (D9222 and D9223).