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

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (22513). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service.  
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation procedures will be considered medically reasonable and necessary for the indicated 
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 to pre-approve this service. Our reviewer says that the 
enrollee does not meet criteria for coverage of the requested service. Our physician reviewer found that there is 
no trial of bracing for fracture treatment indicated in the record. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation (22513).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82040 and 80048 billed for date of service 
March 24, 2023. 
 
You asked the Plan to pay for procedure codes 82040 and 80048. You say that medical records were provided. 
The Plan denied your request. The Plan says payment for code 82040 is bundled into payment for code 80053. 
 
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 82040 
is a column II code to column I code 80053. Code 82040 has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
 
We have also confirmed that code 80048 is a column II code to column I code 80053 with a modifier indicator 
of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 82040 and 80048 
billed for date of service March 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the retina imaging service provided on 
June 15, 2023. 
 
You asked the Plan to reduce the copayment for the retina imaging service. You say that you disagree with the 
cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment per day, for Medicare-covered outpatient diagnostic tests. 
 
You have been asked to pay a $20 copayment for the retina imaging service. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. 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 reduce the copayment for the retina imaging service provided on June 15, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97161 for date of service May 11, 2023, to 
June 1, 2023. 
 
You asked the Plan to pay for procedure code 97161. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 97161 is physical therapy evaluation: low complexity, 
requiring these components: A history with no personal factors and/or comorbidities that impact the plan of 
care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements from 
any of the following: body structures and functions, activity limitations, and/or participation restrictions; A 
clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low 
complexity using standardized patient assessment instrument and/or measurable assessment of functional 
outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family. 
 
We find that CPT code 97161 is payable as billed. Specifically, the medical records do not include 
documentation of the plan of care which includes diagnosis long term treatment goals and type, amount, 
duration and frequency of therapy services therefore the GP modifier is not supported. Based on this 
information, we decided that Medicare rules for coverage of procedure code 97161 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 97161 for date of service May 11, 
2023, to June 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87486, 87502, 87498, 87581, 87634, 87640, 
87651, 87798, U0003, and U0005 for date of service November 16, 2022. 
 
You asked the Plan to pay for procedure codes 87486, 87502, 87498, 87581, 87634, 87640, 87651, 87798, 
U0003, and U0005. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan 
says the services are not payable as 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. 
 
We find that CPT codes 87486, 87502, 87498, 87581, 87634, 87640, 87651, 87798, U0003, and U0005 are not 
payable as billed. Specifically, the submitted Laboratory Requisition indicates that a COVID-19 respiratory 
panel was requested. The submitted documentation does not itemize what tests are included in this panel. 
Based on this information, we decided that Medicare rules for coverage of procedure codes 87486, 87502, 
87498, 87581, 87634, 87640, 87651, 87798, U0003, and U0005 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 87486, 87502, 87498, 87581, 87634, 87640, 87651, 87798, 
U0003, and U0005 for date of service November 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second retainer crown (D6545) provided on February 9, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 9, 2023. 
Therefore, we decided that the Plan does not have to pay for a second retainer crown (D6545) provided on 
February 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight methylenetetrahydrofolate reductase (MTHFR) 
genetic testing (81479) provided on March 21, 2023. 
 
You asked the Plan to pay for genetic testing. You say that the requested testing is medically necessary. The 
Plan denied your request. The Plan says the request is not medically necessary because the records show you 
are not pregnant. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for these genes for all risk factors, 
signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered except for 
pregnant patients. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Medicare rules say that this testing is non-covered except for 
pregnant enrollees. Specifically, the records show you are not pregnant, therefore, you do not meet criteria for 
approval of the requested testing. Therefore, we decided that the Plan does not have to pay for GeneSight 
methylenetetrahydrofolate reductase (MTHFR) genetic testing (81479) provided on March 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) for the upper 
right, upper right, and lower left quadrants provided on April 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that you did not know that this would not be 
covered. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 27, 2022. 
Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) for 
the upper right, upper right, and lower left quadrants provided on April 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA); 
Chlamydia trachomatis, amplified probe technique (87491) and infectious agent detection by nucleic acid 
(DNA or RNA); Neisseria gonorrhoeae, amplified probe technique (87591) provided March 14, 2023.   

You asked the Plan to pay for the laboratory service. You say that this test was ordered by a treating physician 
who makes the professional determination of diagnosis and medical necessity to successfully treat their 
patients. The Plan denied your request. The Plan says under Medicare guidelines, the testing does not meet the 
requirements for approval.  
 
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 this enrollee underwent a cystoscopy and the following month was evaluated for a 
urinary tract infection (UTI) with a broad panel of tests, including sexually transmitted infections (STI) panel. 
There is no clinical information/history to support this broad testing approach. 
 
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 infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, 
amplified probe technique (87491) and infectious agent detection by nucleic acid (DNA or RNA); Neisseria 
gonorrhoeae, amplified probe technique (87591) provided March 14, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0382 billed for June 6, 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 code A0382 is not separately billable. 
 
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 A0382 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code A0382 is statutorily excluded. Based on this information, we decided that Medicare rules for 
coverage of A0328 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code A0382 billed for June 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 01402 for date of service May 9, 2023. 
 
You asked the Plan to pay for procedure code 01402. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the units billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 115 units of CPT code 01402 are not supported in the medical record. The medical record only 
supports 115 units of CPT code 01402. Based on this information, we decided that Medicare rules for coverage 
of procedure code 01402 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 01402 for date of service May 9, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service January 14, 
2022. 
 
You asked the Plan to pay for procedure code 99072. You say that you were a Medicare-certified provider on 
the date of service in question. The Plan denied your request. The Plan says procedure code 99072 is 
considered bundled and not separately payable.  
 
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 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99072 billed for date of service January 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88368, 88369, 88377 and G0452 billed for 
date of service May 15, 2023. 
 
You asked the Plan to pay for procedure codes 88368, 88369, 88377 and G0452. You say that these services 
were necessary and are supported as billed. The Plan denied your request. The Plan says these codes are not 
supported for separate payment. 
 
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 codes 88368, 88369, 88377 and G0452 are column II codes to column I 
code 81455; however, 88368, 88369, 88377 and G0452 were each billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 88368, 88369, 88377 and G0452. Our 
reviewer says that these codes are not supported for separate billing or payment. Our reviewer found the 
documentation provided does not support that these services were unusual non-overlapping services; therefore, 
the use of the XU modifier to bypass the NCCI edit 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 procedure codes 88368, 88369, 88377 and G0452 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 88368, 88369, 88377 and G0452 
billed for date of service May 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a removal of impacted tooth, placement of intra-socket 
biological dressings, and therapeutic parenteral drugs (D7220, D7241, D7922, D9610) provided on May 19, 
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 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a removal 
of impacted tooth, placement of intra-socket biological dressings, and therapeutic parenteral drugs (D7220, 
D7241, D7922, D9610) provided on May 19, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service May 19, 
2023, to June 17, 2023. 
 
You asked the Plan to pay for the billed services. You say that the NOA was submitted. The Plan denied your 
request. The Plan says an NOA instead of a RAP is required. 

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The file shows that a claim with TOB 322 was submitted, identifying a RAP claim. An NOA using TOB 032A 
was not submitted. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for the home health care 
billed for dates of service May 19, 2023, to June 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 20610 billed for date of service July 26, 2022.
You asked the Plan to pay for procedure code 20610. You say that medical records were provided. The Plan denied your request. The Plan says The Plan requested a reopen and noted that per Medicare NCCI Medically Unlikely Edits (MUEs) Practitioner Services effective April 1, 2022, procedure code 20610 has a MAI of 3 and a MUE value of 2 per date of service. Per the 2022 National Physician Fee Schedule, procedure code 20610 has a bilateral indicator of 1. Per NCCI chapter 1, Section V, part 3A ii indicates, if the bilateral surgery indicator is "1," a bilateral surgical procedure must be reported with "1" unit of service and modifier 50 (bilateral modifier). As code 20610 has a bilateral indicator of 1, it must be reported with one unit and a modifier of 50 must be reported. Per these billing guidelines, the Plan has correctly denied the claim for payment as the provider did not bill the code correctly.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid as billed due to the indicator assigned to code 20610. 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 20610 billed for date of service July 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intracept procedure. 
 
You asked the Plan to pre-approve intracept procedure. You say that it is medically necessary. The Plan denied 
your request. The Plan says it is not medically necessity and is considered experimental/investigational.  
 
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 intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation was/is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-
designated basivertebral nerves as being medically necessary and/or reasonable at this time. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision supply provided on January 12, 2023. 
 You asked the Plan to pay for the vision supply. You say that the provider did not accept your insurance. You 
say you would like to be reimbursed the $130 that the Plan allows. The Plan denied your request. The Plan says 
the benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers eyewear every 12 months. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $130 towards eyeglasses on October 21, 
2022, which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of 
the vision supply have not been met. Therefore, we decided that the Plan does not have to pay for the vision 
supply provided on January 12, 2023.  
 
Your complaint about the benefit design is not a valid appeal for medical coverage. This part of your complaint 
is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these 
types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on January 11, 2023, billed 
with codes 87798, 87498, 87502, 87541, 87634, 87641, U0003 and U0005. 
 
You asked the Plan to pay for the laboratory panel 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 a 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 a laboratory 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 laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on January 11, 2023, billed with codes 87798, 87498, 87502, 87541, 87634, 87641, U0003 and 
U0005.