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

 
We decided that the Plan does not have to pay for procedure codes A4556, A4557, A4649, A9279, S1015, 
S8301, and 99072 billed for date of service November 22, 2022. 
 
You asked the Plan to pay for procedure codes A4556, A4557, A4649, A9279, S1015, S8301, and 99072. You 
say that the entire claim should be paid at the in-network level. The Plan denied your request. The Plan says the 
billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services with status indicators I, B, and 
P are not payable. 
 
We find that procedure codes S1015, S8301, and A9279 have a Status Indicator of I on the Physician Fee 
Schedule. Procedure codes A4556, A4557 and A4649 have a status indicator of P on the Physician Fee 
Schedule. Procedure code 99072 has a status indicator of B on the Physician Fee schedule This means that 
procedure codes A4556, A4557, A4649, A9279, S1015, S8301, and 99072 are not separately payable. 
Therefore, we decided that the Plan does not have to pay for procedure codes A4556, A4557, A4649, A9279, 
S1015, S8301, and 99072 billed for date of service November 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the attendant control (E2331) and other accessories 
(K0108 x 8). 
 
You asked the Plan to pre-approve the attendant control and other accessories. You say that the requested items 
are medically necessary. The Plan denied your request. The Plan says the requested items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if an attendant control (E2331) is provided in 
addition to a beneficiary-operated drive control system, it will be denied as non-covered. The rules say that 
Code K0108 must not be used for any component or feature of an expandable controller at the time of initial 
issue. Medicare rules also say that code K0108 is only used for items that do not have a proper HCPCS code. 
 
We looked at the file and Medicare rules. The requested attendant control cannot be covered in addition to a 
beneficiary-operated joystick. Code K0108 cannot be use for any part of the expandable controller and harness 
as they include all the necessary components to operate the controller; therefore, the expandable electronics, 
touch screen display, alternative driver controls, egg switch, and mono extension cable are not covered. The 
requested lateral head rest pads are included with approved code E0995, and the elbow clock pads are included 
with approved code E1007. The calf pads were coded as K0108, but the correct code for these items is E0995, 
which is only for replacement items and not for initial use. The requested Jay Base Wedge is not covered as 
wheelchair seat and back cushions are all-inclusive. Therefore, we decided that the Plan does not have to pre-
approve the attendant control (E2331) and other accessories (K0108 x 8).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0330) on January 9, 2023. 
 
You asked the Plan to pay for the dental services (D0330). You say that you would like to request 
reconsideration of the denied claim. 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 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 your benefit for the requested item or service was exhausted on date of service November 9, 2021. 
Therefore, we decided that the Plan does not have to pay for the dental services (D0330) on January 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous intraoperative monitoring billed with code 95941. 
 
You asked the Plan to pay for code 95941. You say that these services were ordered by an in-network surgeon 
and were the standard of care for the patient's condition. The Plan denied your request. The Plan says this code 
is not covered. The Plan must follow Medicare rules. Medicare rules say that code 95941 is not payable by 
Medicare. Therefore, we decided that the Plan does not have to pay for continuous intraoperative monitoring 
billed with code 95941.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36620 for date of service November 2, 2022. 
 
You asked the Plan to pay for procedure code 36620. 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 36620 is arterial catheterization or cannulation for 
sampling, monitoring or transfusion (separate procedure); percutaneous. 
 
We find that CPT code 36620 is not supported in the medical record. Specifically, the submitted medical 
records do not include documentation to support that arterial catheterization or cannulation for sampling, 
monitoring or transfusion; percutaneous was performed. Based on this information, we decided that Medicare 
rules for coverage of procedure code 36620 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 36620 for date of service November 2, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the removal impacted cerumen requiring instrumentation services 
billed with code 69210 provided on December 8, 2022. 
 
You asked the Plan to pay for the removal impacted cerumen requiring instrumentation services. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says that the provider did not bill as 
required by Medicare coding regulations. 
 
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 has denied this code due to the provider did not bill as required by 
Medicare coding regulations. The documentation did not include an explanation on why this code was not 
billed correctly according to Medicare coding regulations. No other Plan denial rationale was provided. The 
Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the removal impacted 
cerumen requiring instrumentation services billed with code 69210 provided on December 8, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0444, 99213, and 94760 billed for date of 
service October 24, 2022. 
 
You asked the Plan to pay for procedure codes G0444, 99213, and 94760. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for codes G0444, 99213, and 94760 is 
bundled into payment for other codes. 
 
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 G0444 
is a column II code to column I code G0438 with a modifier indicator of 0. The column II code is therefore not 
payable. In this case, we have confirmed that code 99213 is a column II code to column I code G0438. This 
claim has not been billed with an appropriate modifier to bypass the edit. Code 94760 has a status indicator of 
T. This means code 94760 is bundled into payment for code G0101 billed on the same date of service by the 
same provider. 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 G0444, 99213, and 94760 billed for date of 
service October 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81345) provided on October 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81345) provided on October 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for MTHFR (5,10-methylenetetrahydrofolate reductase) gene 
analysis (81291) provided on November 29, 2022. 
 
You asked the Plan to pay for MTHFR gene analysis. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that MTHR gene analysis is not considered to be 
clinically efficacious. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of MTHFR gene analysis have not been met. Therefore, we decided that the Plan does not have to pay 
for MTHFR (5,10-methylenetetrahydrofolate reductase) gene analysis (81291) provided on November 29, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that additional therapy is medically necessary. 
The Plan denied your request. The Plan says that the additional seven visits are not medically necessary. The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee has an effective home exercise program of repetitive 
exercise. The continued input from a skilled therapist beyond the additional five visits is 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve seven additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87900 for date of service November 7, 2022. 
 
You asked the Plan to pay for procedure code 87900. 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 87900 is infectious agent drug susceptibility phenotype 
prediction using regularly updated genotypic bioinformatics. 
 
We find that CPT code 87900 is not supported in the medical record. Specifically, the laboratory results 
provided in the medical record does not include a rapid test kit that shows collected samples of the infection 
agent, by a swab or aspirations using several reagents. Based on this information, we decided that Medicare 
rules for coverage of procedure code 87900 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 87900 for date of service November 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instruction (D1330) provided on January 10, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you did not know that the provider was an out-
of-network provider because they were previously in-network. The Plan denied your request. The Plan says the 
denial of payment for this service is correct, because the oral hygiene instruction 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 Plan's 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 oral 
hygiene instruction (D1330) provided on January 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for crown - porcelain/ceramic (D2740) provided on July 
12, 2021. 
 
You asked the Plan to pay more for the dental services. You say that you were not aware the provider was out-
of-network, and your benefit amount was not reached as of the appointment. 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 Plan paid 
$262 for services on March 29, 2021, $95 for services on April 29, 2021, $120 for services on October 13, 
2021, $188.12 for services on December 1, 2021, and $334.88 for services on July 12, 2021 ($262 + $95 + 
$120 + $188.12 + $334.88 = $1,000), which is the annual maximum of $1,000. The record show your benefit 
for the requested item or service was exhausted on date of service July 12, 2021. Therefore, we decided that the 
Plan does not have to pay more for crown - porcelain/ceramic (D2740) provided on July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing billed with code 83789 for date(s) of 
service January 3, 2023. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for laboratory testing billed with 
code 83789 for date(s) of service January 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service December 
12, 2022. 
 
You asked the Plan to pay for procedure code 87634. You say that this service was necessary and is supported 
as billed. The Plan denied your request. The Plan says the payment for code 87634 is included in the payment 
for code 87798. Although a modifier was used in this case, the records do not support the use of this modifier. 
 
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 87634 is a column II code to column I code 87798; however, 87634 
was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 87634. Our reviewer says that this code is 
not supported based on Medicare coding standards. Our reviewer found code 87634 is not supported as a 
separately reportable procedure. The medical records show that a respiratory panel was performed to test for 
multiple respiratory viruses. According to CPT rules, there is a more specific way to report this, based on the 
number of assays tested. 
 
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 87634 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87634 billed for date of service December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0364), and a pulp vitality test 
(D0460). 
 
You asked the Plan to pay for D0364 or D0460. You say that this dental work should be covered. The Plan 
denied your request. The Plan says these services are not covered benefits. 
 
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 cone 
beam CT capture (D0364), and a pulp vitality test (D0460).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2313, E2311, E2377). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that the requested items are medically 
necessary. The Plan denied your request. The Plan says that the upgraded electronics are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that upgraded electronics are covered when it is medically 
necessary to control the power options through the joystick. 
 
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 upgraded electronics. Our reviewer 
says that these items are not medically necessary. Our physician reviewer found that the enrollee has adequate 
strength to manage standard power drive controls. This request exceeds what is necessary to meet the enrollee's 
needs. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics (E2313, E2311, E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cushioned headrest (E0955) for a power wheelchair. 
 
You asked the Plan to pre-approve a cushioned headrest. You say that the requested item is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested item is 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 a cushioned headrest. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provided records in this case do not document that the enrollee has a manual tilt-in-
space, manual semi or fully reclining back on a manual wheelchair, a manual fully reclining back on a power 
wheelchair, or power tilt and/or recline power seating system. 
 
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 cushioned headrest have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a cushioned headrest (E0955) for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arm and leg artery ultrasound provided on September 20, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ultrasound. You say that the services billed are supported in the records. The 
Plan denied your request. The Plan says enrollees must receive their care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided this item/service at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for this item/service. Therefore, 
we decided that the Plan does not have to pay for the arm and leg artery ultrasound provided on September 20, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retreatment of a root canal (D3348) provided on January 
31, 2023. 
 
You asked the Plan to pay for the retreatment of a root canal. You say that you would like the Plan to pay for 
this dental work. The Plan denied your request. The Plan says D3348 is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
retreatment of a root canal (D3348) provided on January 31, 2023.