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

 
We decided that the Plan does not have to pay for procedure code G2074 billed for date of service December 
14, 2022. 
 
You asked the Plan to pay for procedure code G2074. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is statutorily excluded. 
 
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 G2074 has a Status Indicator of X on the Physician Fee Schedule. This means that procedure code G2074 is statutorily excluded from payment. Based on this information, we decided that 
Medicare rules for coverage of procedure code G2074 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code G2074 billed for date of service December 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-pneumatic compression device with garment. 
 
You asked the Plan to pre-approve non-pneumatic compression device. You say that this specific device is a 
better option for the enrollee. The Plan denied your request. The Plan says there is insufficient evidence in the 
medical literature to support that the Dayspring device is as effective as a pneumatic compression device. 
 
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 non-pneumatic compression device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the requested device has not been shown to be superior to other 
standard treatment for the enrollee's condition. Studies do not indicate the Dayspring device improves an 
individual's function or general health.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-pneumatic compression device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a non-pneumatic compression device with garment.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on February 9, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim for this 
molecular pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on February 9, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 billed for January 18, 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 procedure code G0482 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 G0482 is definitive drug testing, 15-21 drug classes. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records show that only 
nine drug classes were testing. 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 G0482 
billed for January 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 81479 for date of service 
October 19, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and will 
directly impact clinical decision making. The Plan denied your request. The Plan says the claim for this 
molecular pathology testing did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services billed with code 81479 
for date of service October 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87798, 87481) provided on December 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single service. Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, 
we decided that the Plan does not have to pay for lab services (87798, 87481) provided on December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99496 billed for date of service July 20, 
2022.  
 
You asked the Plan to pay for procedure code 99496. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99496 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. This code can only be billed only once per patient within 30 days of discharge. 
Another transitional care management service may not be reported by the same individual or group for any 
subsequent discharge(s) within the 30 days. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99496 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99496 billed for date of service July 20, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for endovascular revascularization (procedure code 37233) rendered on 
February 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 that procedure code 37233 is not supported by the records submitted. 
 
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 37233 is "Revascularization, endovascular, open or percutaneous, tibial/peroneal (TP) artery, unilateral, 
each additional vessel; with atherectomy, includes angioplasty within the same vessel, when performed (List 
separately in addition to code for primary procedure)." 
 
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 in this case, CPT 37229 was reported 
for TP, and the additional atherectomy in anterior tibial.  The tibial/peroneal trunk is considered a separate 
vessel from the anterior tibial artery.  Therefore, this procedure should be covered. 
 
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 
endovascular revascularization (procedure code 37233) rendered on February 23, 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: Unfavorable

 
We decided that the Plan does not have to pay more for an oral evaluation (D0120), the intraoral radiographic 
images (D0220 and D0230), bitewings (D0274), a cleaning (D1110), the application of fluoride (D1206), the 
resin-based composite (D2330), and the endodontic therapy (D3310) for tooth #10 provided by an out-of-
network provider on January 12, 2023, and February 23, 2023. 
 You asked the Plan to pay more for the dental services. You say that the provider would not accept your card 
and the payments the Plan made do not seem right to you. The Plan denied your request. The Plan says you are 
responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider.  
 
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. 
 
For the oral evaluation (D0120) the total amount billed was $63 and the total allowed amount was $28 leaving 
a difference of $35 ($63 billed - $28 allowed). The total amount billed for the intraoral radiographic image 
(D0220) was $38 and the total allowed amount was $11 leaving a difference of $27 ($38 billed - $11 allowed). 
The total amount billed for the intraoral radiographic image (D0230) was $35 and the total allowed amount was 
$14 leaving a difference of $21 ($35 billed - $14 allowed). The total amount billed for the bitewings (D0274) 
was $80 and the total allowed amount was $38 leaving a difference of $42 ($80 billed - $38 allowed). The total 
allowed amount for the cleaning (D1110) was $110 and the total allowed amount was $54 leaving a difference 
of $56 ($110 billed - $54 allowed). The total billed amount for the application of fluoride (D1206) was $51 and 
the total allowed amount was $24 leaving a difference of $27 ($51 billed - $24 allowed). The total amount 
billed for the resin-based composite was $181 and the total allowed amount was $87 leaving a difference of 
$94 ($181 billed - $87 allowed). The total allowed amount for the endodontic therapy (D3310) was $839 and 
the total allowed amount was $311 leaving a difference of $528 ($839 billed - $311 allowed). The total 
difference amount for all the dental services was $830 ($35 difference + $27 difference + $21 difference + $42 
difference + $56 difference + $27 difference + $94 difference + $528 difference). 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for an oral evaluation (D0120), the intraoral 
radiographic images (D0220 and D0230), bitewings (D0274), a cleaning (D1110), the application of fluoride 
(D1206), the resin-based composite (D2330), and the endodontic therapy (D3310) for tooth #10 provided by an 
out-of-network provider on January 12, 2023, and February 23, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound billed with code 76642-26-RT for December 
14, 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 billed diagnosis code does not match the rendered services. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the billed diagnosis code does not match the 
laterality of the rendered services. 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 the ultrasound 
billed with code 76642-26-RT for December 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spinal surgery and myocardial infarction. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollees 
medical status does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit 
from additional physical and occupational therapy but the documentation does not support that the enrollee 
requires or can fully tolerate an intensive IRF program given her history of fatigue in therapy. The requested 
IRF admission 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve a PET scan.  
 
You asked the Plan pre-approve the PET scan. You say that it is medically necessary to complete PET brain 
imaging to help confirm the underlying cause of the enrollee's dementia. The Plan denied your request. The 
Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 pre-approve the PET scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the records provided for review indicated that 
the enrollee was suspected of having AD with features of vascular dementia. There was no indication of FTD 
or a suspicion of FTD. In as much, the base requirement of the NCD for performance of a PET scan would not 
be satisfied. 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have pre-approve a PET scan.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services billed for date of service January 12, 2023. 
 
You asked the Plan to pay for the medical services. You say that these diagnosis codes are valid. The Plan 
denied your request. The Plan says you billed this claim with an invalid pair of diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of I20.0 and I25.10. Code I25.10 is an Excludes1 code under 
code I20.0, so these two diagnoses cannot be billed together. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services billed for date of service January 12, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (92611, 74230, 74240) provided on 
February 10, 2023. 
 You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Procedures and examinations which are not 
covered under the portable x-ray provision include procedures involving the use of contrast media or the 
administration of a substance to the patient. 
 
We looked at the file and Medicare rules. The procedure performed required the patient to swallow Barium. 
Based on this information, we decided that Medicare rules for coverage of the radiology services have not been 
met. Therefore, we decided that the Plan does not have to pay for radiology services (92611, 74230, 74240) 
provided on February 10, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the dental services on March 23, 2023. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied claim. The Plan denied your request. The Plan says that the criteria for approval have not been 
met. 
 
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 reviewer says 
that the service is medically necessary. Our physician reviewer found the documentation provided meets the 
criteria for coverage for a crown restoration (D2740) for tooth #12. 
 
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 
pre-approve the dental services on March 23, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 provided on June 6, 2022.