Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 sensor and reader. 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 sensor and reader. You say that you need the sensor 
and reader. The Plan denied your request. The Plan says you are not receiving insulin and have not had a 
documented hypoglycemic episode, so the CGM is not medically necessary and not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin or have a 
history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage 
of the FreeStyle Libre 2 sensor and reader have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a FreeStyle Libre 2 sensor and reader.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete maxillary/mandibular overdentures, endosteal 
implants, custom fabricated abutment (D6057, D5865, D5863, D6010). 
 
You asked the Plan to pre-approve 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 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 pre-approve 
complete maxillary/mandibular overdentures, endosteal implants, custom fabricated abutment (D6057, D5865, 
D5863, D6010).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the neurosurgery procedure to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the neurosurgery procedure. You say that you were recommended to have 
the procedure done. The Plan denied your request. The Plan says you must receive your 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the item/service at issue in this appeal. We found no exception that would require 
the Plan to pre-approve this item/service. Therefore, we decided that the Plan does not have to pre-approve the 
neurosurgery procedure to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connector. 
 
You asked the Plan to pre-approve the electronic connector. You say that you do not agree with this denial. The 
Plan denied your request. The Plan says there is not a medical need to control the requested 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 connector. Our reviewer 
says that the requested electronic connector is not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records show that the enrollee has sufficient strength and function 
in upper extremities to manage standard power drives. Therefore, the reviewer found that the requested 
electronic connector is not medically reasonable or 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 electronic connector have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the electronic connector.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 16, 2023, billed with 
codes 87541, 87581, 87651, 87486, 87640, 87641, and 87150. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 

The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
The file shows that an upper respiratory panel test was provided. We looked at the file and Medicare rules. This 
NGS panel was not billed with a single code as required. The records do not show that the testing billed with 
the -59 modifier were separate and distinct services. Based on this information, we decided that Medicare rules 
for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have 
to pay for the genetic testing provided on May 16, 2023, billed with codes 87541, 87581, 87651, 87486, 87640, 
87641, and 87150.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 provided on June 13, 2023. 
 
You asked the Plan to pay for procedure code 99223. You say that the medical records support the billing of 
code 99223. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99223. 
 
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 99223 is Initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
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 99223. Our reviewer says that the medical 
records do not support the billing of code 99223. Our reviewer found the documentation from this date 
describes the enrollee as experiencing hypoglycemia after taking glipizide. Vitals were stable. The enrollee was 
alert. Although the documentation describes an appropriate history and examination, it does not support a high 
level of medical decision making as there were no complexities noted or major treatment changes. Also, the 
note describes the duration of the encounter as being 40 minutes, not meeting the required 75 minutes to justify 
the code, 99223. 
 
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 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 provided on June 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tuberculosis test, cell mediated immunity antigen 
response measurement (86481) provided June 30, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that please review and reconsider these claim 
lines for payment. The Plan denied your request. The Plan says tuberculosis testing as screening for respiratory 
tuberculosis (Z11.1) is not a covered benefit.  
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the laboratory testing, was requested solely for screening purposes. The records 
show this as billed with diagnosis code Z11.1: encounter for screening for respiratory tuberculosis. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the tuberculosis test, cell mediated immunity antigen response measurement (86481) provided June 30, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 20, 2023, billed with 
multiple codes including 81433. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 20, 2023, billed with multiple codes including 81433.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital inpatient or observation care, per day, for 
the evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and high level of medical decision making. When using total time on the date of the encounter for code 
selection, 75 minutes must be met or exceeded. (99223) provided on May 16, 2023. 
 
You asked the Plan to pay for initial hospital inpatient care. You say that the medical records support code 
99223 and should be paid. The Plan denied your request. The Plan says that the medical records did not provide 
sufficient documentation to support code 99223. 
 
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 99223 is initial hospital inpatient care.  
We asked our physician 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 initial hospital inpatient care. Our physician found that 
the medical records did not include a comprehensive history or examination. The records did not support that 
there was a medical decision making of high complexity. Therefore, CPT code 99223 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of initial hospital inpatient care have not been met. Therefore, we decided that the 
Plan does not have to pay for the initial hospital inpatient or observation care, per day, for the evaluation and 
management of a patient, which requires a medically appropriate history and/or examination and high level of 
medical decision making. When using total time on the date of the encounter for code selection, 75 minutes 
must be met or exceeded. (99223) provided on May 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing, of 15-21 drug classes (G0482) 
provided April 18, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that please review the attached documents and 
reconsider the claim for payment. The Plan denied your request. The Plan says under Medicare rules, the 
number of definitive urine drug classes requested 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 pay for the laboratory service. 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 chronic neck and back pain and is taking oxycodone. The enrollee is 
doing a home exercise program, heat and cold compresses as well as non-steroidal anti-inflammatory drugs 
(NSAIDs). There is no documentation of early refills, lost medications, abuse or diversion. There is no 
documentation of abnormal qualitative drug screen and no indication beyond the opiate class for definitive drug 
testing. The testing was not medically reasonable and 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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the definitive drug testing, of 15-21 drug classes (G0482) provided April 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 14, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from November 14, 2023, forward. You say that 
the services at issue were medically necessary. The Plan denied your request. The Plan says the services at 
issue were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from 
November 14, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an 
acute inpatient mental health treatment beyond the date in question of November 14, 2023, forward. Our 
physician reviewer found the enrollee did not require inpatient mental health treatment beyond November 14, 
2023, as he was not a danger to himself or others and did not have any delusions, auditory or visual 
hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not 
appear that the services for the dates in question were reasonably expected or medically necessary to improve 
the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from November 14, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 14, 
2023, forward.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of aorta (93978) provided on April 4, 2023. 
 
You asked the Plan to pay for the duplex scan. You say that the medical records support code 93978 and should 
be paid. The Plan denied your request. The Plan says CPT code 93978 represents a complete duplex scan pf 
aorta, inferior vena cava, iliac vasculature, or bypass grafts. The medical records indicate that there was a 
limited study performed. Therefore, code 93978 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 93978 is duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study. 
 
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 duplex scan. Our reviewer found that the procedure 
report does not support a complete duplex scan.  The report documents that there was a limited arterial duplex 
of the bilateral popliteal arteries performed. There is a more specific code to report for limited study. 
 
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 duplex scan have not been met. Therefore, we decided that the Plan does not 
have to pay for duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study. 
(93978) provided on April 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (87635) provided on June 7, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87635 is "Infectious agent detection by nucleic acid 
(DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease 
[COVID-19]), amplified probe technique". 
 
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 use of code 87635 is 
not supported by the records provided. Our reviewer found that the medical records do not support that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing was administered. The lab performed is for 
urinary tract infection, but this does not include SARS-CoV-2 testing. 
 
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 the services (87635) provided on June 7, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for codes 87481, 87491, 87591, and a third unit of 87801 billed for March 
10, 2023. 
 
You asked the Plan to pay for codes 87481, 87491, 87591, and a third unit of 87801. You say that these codes 
are documented in the records. The Plan denied your request. The Plan says that these codes 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 81801 is infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified 
probe(s) technique. The definition of 87481 infectious agent detection by nucleic acid (DNA or RNA); Candida 
species, amplified probe technique. The definition of 87491 is infectious agent detection by nucleic acid (DNA 
or RNA); Chlamydia trachomatis, amplified probe technique. The definition of 87591 is infectious agent 
detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for codes 87481, 87491, 87591, and a third unit of 87801. Our 
reviewer says that these codes are supported in the records. Our reviewer found the records show that these 
specific tests were 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 codes 87481, 87491, 87591, and a third unit of 87801 have been met. Therefore, 
we decided that the Plan has to pay for codes 87481, 87491, 87591, and a third unit of 87801 billed for March 
10, 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the guided tissue regeneration (D4267) provided on June 30, 2023.  
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says that the provider did not change or withdraw the inappropriate procedure code and 
it will not be covered in this case. 
 
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 pay for the dental services. Our reviewer says that 
the request was medically necessary, and the correct procedure code was applied. Our physician reviewer 
found that guided tissue regeneration after extraction is a procedure that helps strengthen and regenerate lost 
tissue. When bone is grafted to replace the bone lost, a barrier is placed to prevent soft tissue from infiltrating 
the area between the new bone and bone being restored. This assures a good bonding and sufficient bone for 
dental implant placement as in this case. The documentation provided indicates that this procedure was 
performed and was medically reasonable and necessary. 
 
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 been met. Therefore, we decided that the Plan has to 
pay for the guided tissue regeneration (D4267) provided on June 30, 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.