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

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service March 27, 
2023. 
 You asked the Plan to pay for procedure code 11721. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 11721 is bundled into payment for code 11055. 
 
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 11721 
is a column II code to column I code 11055. 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 11721 billed for date of service March 27, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on August 23, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the Plan allows for 40% of coverage for mental 
health providers outside of the Plans network and prior reimbursement has been paid to you. The Plan denied 
your request. The Plan says this provider is not part of the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on 
August 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns and pontics (D6750, D6240, D6752). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as the 
enrollee disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as 
the enrollee does not meet the clinical requirements to be approved. 
 
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 the dental 
services 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 the dental services. Our physician 
reviewer found that a review of the documentation indicates that the periodontal support of tooth #9 is poor 
(less than 50% bone support).  This abutment does not appear to be adequate to support a fixed bridge, 
therefore the prognosis for a fixed bridge in this area is poor and does not meet the criteria for coverage. 
Criteria is unmet. 
 
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 the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve retainer crowns and pontics (D6750, D6240, D6752).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical and lumbar facet joint injections (64490, 
64493, 64491, 64494). 
 
You asked the Plan to pre-approve facet joint injections. You say that the enrollee has had minor relief from an 
epidural steroid injection for their neck pain. The Plan denied your request. The Plan says the facet joint 
injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary only when there is an absence of untreated radiculopathy or neurogenic claudication 
(except for radiculopathy caused by facet joint synovial cyst) and no non-facet pathology per clinical 
assessment or radiology studies that could explain the source of the patients pain, including but not limited to 
fracture, tumor, infection, or significant deformity. 
 
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 facet joint injections. Our reviewer says 
that the requirements for coverage have not been met. Our physician reviewer found there is documentation of cervical and lumbar radiculopathy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cervical and lumbar facet joint injections (64490, 64493, 64491, 64494).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 7, 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 services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on August 7, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72020 billed for date of service July 24, 
2023. 
 You asked the Plan to pay for procedure code 72020. You say that the service was billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 72020 is bundled into payment for code 
72110. 
 
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 72020 
is a column II code to column I code 72110. 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 72020 billed for date of service July 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 12, 2023. 
 
You asked the Plan to pay for laboratory services. You say that samples sent from clinics and providers for 
patients they have determined require such testing. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on August 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial mandibular denture (D5214), and a complete 
maxillary denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that your current dentures are too thin. 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 your benefit for the requested item or service was exhausted on date of service D5214 and D5110. 
Therefore, we decided that the Plan does not have to pre-approve a partial mandibular denture (D5214), and a 
complete maxillary denture (D5110).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from January 2, 2023, to 
February 13, 2023.  
 
You asked the Plan to pay for the psychotherapy. You say that this therapist is providing a service that helps 
reduce your stress and anxiety. The Plan denied your request. The Plan says this provider type not eligible for 
Medicare on the dates of service appealed. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from  
January 2, 2023, to February 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hip orthosis (L1686, L2624) provided on August 1, 2023.  
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the records do not show an appropriate face-to-face encounter. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records in this case document back pain with osteoarthritis but the medical records do 
not document a hip disorder for which a hip orthosis is needed. The provided records in this case also do no 
document an appropriate face to face encounter for the hip orthosis.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a hip orthosis (L1686, L2624) provided on August 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the right lumbar spine 
(64635, 64636). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that for each covered spinal region no more than two (2) 
radiofrequency sessions will be reimbursed per rolling 12 months.  
 
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 radiofrequency ablation. Our reviewer 
says that the requirements for coverage have not been met. Our physician reviewer found the record shows that 
the enrollee has had three radiofrequency sessions in the past 12 months, exceeding the coverage limitation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation of the right lumbar spine (64635, 64636).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code P9603 billed for September 11, 2022. 
 
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 procedure code P9603 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 P9603 is travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually travelled. 
 
We find that CPT code P9603 is not supported in the medical record. Specifically, the documentation does not 
indicate that a technician drew the specimen. 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 pay for 
procedure code P9603 billed for September 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from April 19, 2022, to 
May 18, 2022. 
 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 NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 19, 2022. The NOA was not received by the Plan until November 30, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from April 19, 2022, to May 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for one additional unit of procedure code A4315 provided on 
June 23, 2023. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 A4315 is "Insertion tray with drainage bag with 
indwelling catheter, foley type, two-way, all silicone." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not support the 
additional units or the additional insertion tray. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for one additional unit of procedure code A4315 provided on June 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression devices (E0675, E0673) 
provided on June 19, 2023. 
 
You asked the Plan to pay for the pneumatic compression devices. You say that these devices were provided 
for use during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility 
for a procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home.  
  Therefore, we decided that the Plan does not have to pay for the pneumatic compression devices (E0675, 
E0673) provided on June 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle. 
 
You asked the Plan to pre-approve the vehicle. You say that this is medically necessary. The Plan denied your 
request. The Plan says the coverage criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 vehicle. Our reviewer says that the 
requested device is not medically reasonable or necessary. Our physician reviewer found that the documentation indicates the patient has a mobility limitation but the documentation is not clear that this 
limitation is unable to overcome his mobility limitations with a cane, walker or manual wheelchair. The 
documentation does not reveal that the patient's home provides adequate access between rooms, maneuvering 
space, and surfaces for the operation of the power operated vehicle that is requested. 
 
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 vehicle have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for psychotherapy provided from May 4, 2023, to 
June 28, 2023. 
 
You asked the Plan to reimburse you for the psychotherapy. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the provider is not under contract with the health Plan 
and is not certified with Medicare.  
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
psychotherapy provided from May 4, 2023, to June 28, 2023.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency room services (procedure code 99285) rendered on April 
21, 2023. 
 
You asked the Plan to pay for the services. You say that the criteria was not met for CPT 99285. The Plan 
denied your request. The Plan says that the criteria was not met for CPT 99285. 
 
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 99285 is "Emergency department visit for the evaluation and management of a patient, which requires a 
medically appropriate history and/or examination and high level of medical decision making." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that an appropriate history and physical 
were performed. The enrollee presented with a headache. Broad differential was considered, and labs, 
electrocardiogram, and other imaging was done. The enrollee was treated with IV morphine. The 
documentation supports a high level of complexity for the medical decision making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
emergency room services (procedure code 99285) rendered on April 21, 2023.  
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the diabetic sensors billed with code A9276 received on December 21, 
2022. 
 
You asked the Plan to pay for the diabetic sensors. You say that you were not advised that you needed pre-
authorization. The Plan denied your request. The Plan says that the items received are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the diabetic sensors by a contract provider. The file does not show that the Plan provided 
notice that the diabetic sensors would not be covered. Under Medicare rules, this means the diabetic sensors is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the diabetic sensors billed 
with code A9276 received on December 21, 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.