Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 99152 and 99153. We decided that the Plan does not 
have to pay for procedure codes J3010, 36140 and 36247.  

You asked the Plan to pay for procedure codes J3010, 99152, 99153, 36140 and 36247 billed for date of 
service November 16, 2022. You say that these services were necessary and are supported in the medical 
record. The Plan says that these services are not supported for reporting. 
 
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 decided that the Plan has to pay for procedure codes 99152 and 99153.  
 
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 99152 and 99153. Our reviewer says that 
these codes are supported. Our reviewer found that the record contains the provider's face to face time 
performing moderate sedation and a trained independent observer was also present. The criteria to report 
moderate sedation has been met. 
 
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 99152 and 99153 have been met. Therefore, we decided that 
the Plan has to pay for procedure codes 99152 and 99153.  
 
We also decided that the Plan does not have to pay for procedure codes J3010, 36140 and 36247. 
 
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 J3010, 36140 and 36247. Our reviewer says 
that these codes are not supported. Our reviewer found that code 36140 is included in the angioplasty and 
would not be separately reportable according to CPT guidelines. Code 36247 is also not supported, as the 
record states that angioplasty, including stenting and arthrectomy was performed at the same sites as the 
selective catheter placement. The catheter placement is included in the peripheral angioplasty procedures and is 
not separately reportable according to CPT guidelines. In addition, code J3010 cannot be verified. Although the 
record states fentanyl was provided, the dosage was not documented. The quantity/units of this code cannot be 
verified. 
 
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 J3010, 36140 and 36247 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes J3010, 36140 and 36247. 
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth 
#31. 
 
You asked the Plan to pre-approve the dental services. You say that the dental procedures are medically 
necessary because of your medical condition. The Plan denied your request. The Plan says your annual dental 
benefit for the year 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 that the Plan paid $145 for dental services on February 8, 2023. On April 6, 2023, the Plan paid $1,812 
for dental services. On May 8, 2023, the Plan paid $23 for dental services. On May 11, 2023, the Plan paid $20 
for dental services. For the year of 2023 the Plan paid $2,000 ($145 paid + $1,812 paid + $23 paid + $20 paid) 
for dental services; therefore, your annual dental benefit for the year was exhausted on the date of service of 
May 11, 2023. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) and core 
buildup (D2950) for tooth #31.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foundation pain index (FPI) testing provided on March 21, 
2022. 
 
You asked the Plan to pay for foundation pain index (FPI) testing. You say that this is the only lab that 
performs this 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 foundation pain index 
(FPI) testing provided on March 21, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the residual limb support and upgraded electronic connection. 
 
You asked the Plan to pre-approve the residual limb support and upgraded electronic connection. You say that 
you are not able to life the enrollee up to put them into bed. You also say that the enrollee has pressure sores 
from leaning to one side due to the current wheelchair being broken. The Plan denied your request. The Plan 
says that there is no medical need for a residual limb support. The Plan also says that an upgraded electronic 
connection is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 residual limb support and upgraded 
electronic connection. Our reviewer says that the requested residual limb support and upgraded electronic 
connection are considered medically reasonable and necessary in this case. Our physician reviewer found the 
provided documentation indicates that you cannot perform pressure relief independently due to weakness and 
requires a power wheelchair with power tilt and recline for adequate pressure relief and positioning. The 
complexity of your seating and positioning needs necessitates a more complex Group 3 power wheelchair base. 
The upgraded electronic connection is necessary to operate the Group 3 power wheelchair base and the three 
power options, including tilt and recline, via a joystick. The reviewer found that you have a history of femur 
fracture and hip dislocation and restricted left knee range of motion. The reviewer found that you require the 
residual limb support for positioning given the deficits in your left lower extremity. Therefore, the reviewer 
found that the residual limb support and upgraded electronic connection are 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 residual limb support and upgraded electronic connection have been met. 
Therefore, we decided that the Plan has to pre-approve the residual limb support and upgraded electronic 
connection.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87491-59 and 87640-59 billed for date of 
service January 10, 2023. 
 
You asked the Plan to pay for the billed services. You say that the coding is approved by Medicare. The Plan 
denied your request. The Plan says the billed codes cannot be verified. 
 
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 87491 is infectious agent detection by nucleic acid (DNA 
or RNA); Chlamydia trachomatis, amplified probe technique. We find that CPT code 87491 is not supported in 
the medical record. The records do not show that this test was performed.  
 
The file shows that a urinary tract infection panel was provided. We find that code 87640, billed with the -59 
modifier, was not a distinct procedural service. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
87491-59 and 87640-59 billed for date of service January 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a screening mammogram provided on September 27, 2022. 
 
You asked the Plan to pay for a screening mammogram. You say that the provided medical records support the 
procedure. 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 a screening 
mammogram provided on September 27, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 87900. We decided that the Plan does not have to pay 
for procedure codes 87640, 87652 and 87798.  You asked the Plan to pay for procedure codes 87640, 87652, 87798 and 87900 billed for date of service 
February 1, 2023. You say that this test was necessary and was reported appropriately. The Plan says that these 
codes are not supported in the medical records. 
 
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 decided that the Plan has to pay for procedure code 87900.  
 
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 87900. Our reviewer says that this code is 
supported in the medical record. Our reviewer found that the record contains a susceptibility report showing 
which drugs were tested, which were susceptible, and which were resistant. 
 
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 87900 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 87900.  
 
We also decided that the Plan does not have to pay for procedure codes 87640, 87652 and 87798. 
 
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 87640, 87652 and 87798 Our reviewer says 
that these codes are not supported in the medical record. Our reviewer found that the record does not contain 
results, either positive or negative, for Staph A testing or Strep A testing. It cannot be verified that the tests 
described with codes 87640 and 87652 were performed. In addition, code 87798 cannot be verified as the 
record does not state which infectious agents that are not otherwise specified were tested for. It cannot be 
verified that these 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 procedure codes 87640, 87652 and 87798 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87640, 87652 and 87798. 
 
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 an office visit provided on February 09, 2023. 
 
You asked the Plan to pay for an office visit. You say that you would like a reconsideration of the denied claim. 
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 an office visit provided 
on February 09, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient psychiatric care from July 3, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that this is medically 
necessary. The Plan denied your request. The Plan says that this is 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 hospital services. 
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 July 3, 2023, forward. Our physician reviewer found the enrollee is 
noted to respond to internal stimuli and is noted to be "floridly psychotic". Her psychiatric provider documents 
that petition to administer medications involuntarily has been submitted. There is also documentation that she 
is unable to provide care for herself or guard herself from harm and will not improve without treatment. The 
provider appears to have submitted for court petition and is working towards providing care. The progress 
notes indicate the enrollee has refused to interact with the psychiatric provider therefore there is no 
documentation that she denies any suicidal or homicidal ideation.  As of the last covered day, the 
documentation indicates the enrollee remained uncooperative with treatment and required intervention by 
security. The enrollee was exhibiting florid psychosis and was not attending to her activities of daily living. 
The enrollee has chronic symptoms and is unable to care for herself. The documentation indicates her family is 
not comfortable having her at home. The available medical records support that continued inpatient care is 
needed beyond the last covered day due to the enrollee being persistently or acutely disabled and unable to 
provide care for herself.    

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 hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve inpatient psychiatric care from July 3, 2023, forward.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a SNF visit provided from December 9, 2022, to January 7, 
2023. 
 
You asked the Plan to pay for a SNF visit. You say that you are requesting a reconsideration of the denied SNF 
services. The Plan denied your request. The Plan says the enrollee's 100-day SNF benefit is exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from August 19, 2022, 
to December 8, 2022. The Plan has covered 100 days of SNF care.  
 
 
  Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for a SNF visit provided from December 9, 2022, to January 7, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77062 billed for date of service February 17, 
2023. 
 
You asked the Plan to pay for procedure code 77062. You say that the claim is billed correctly and should be 
paid. 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 providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77062 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77062 billed for date of service February 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 13, 
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 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 February 14, 2023. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
March 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown, intraoral x-rays, and filling (D0220, D0230, D2740, 
D2392) provided on April 5, 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 dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a crown, intraoral x-rays, and filling (D0220, D0230, D2740, D2392) provided on April 5, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy visits. 
 
You asked the Plan to pre-approve the physical therapy visits. You say that the enrollee has declined in walking 
and mobility since therapy has stopped. The Plan denied your request. The Plan says 8 additional physical 
therapy 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 physical therapy visits. 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 previously been treated with 
outpatient therapies and should be independent with a home exercise program. The enrollee has no recent 
injury or a decline in function. The additional therapy services are not appropriate duration and frequency for 
treatment of the enrollees medical condition and therefore 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 the physical therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 8 additional physical therapy visits.