Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service January 24, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that these anesthesia services should be paid at 
the in-network rate. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service January 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87150 billed for date of service October 18, 
2022. 
 
You asked the Plan to pay for procedure code 87150. You say that this service was reported correctly. The Plan 
denied your request. The Plan says the payment for code 87150 is included in the payment for code 87500. 
Although this service was billed with a modifier, the records do not support that this modifier was used 
appropriately. 
 
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 87150 is a column II code to column I code 87500; however, 87150 
was 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 code 87150. Our reviewer says that the XU 
modifier is not supported for reporting with this code. Our reviewer found the documentation does not support 
an unusual non-overlapping service, and therefore 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 code 87150 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87150 billed for date of service October 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildups (D2950 x 2), pontics  
(D6245 x 7) and retainer crowns (D6740 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that your bridge is breaking off and it is hard 
for you to chew. 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 authorization number 0044174365. 
Therefore, we decided that the Plan does not have to pre-approve core buildups (D2950 x 2), pontics  
(D6245 x 7) and retainer crowns (D6740 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the power seat elevation system. You say that you disagree with the denial. 
The Plan denied your request. The Plan says that the requested power seat elevation system is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is not primarily 
medical in nature.  
 
The power seat elevation system does not serve a medical purpose. Therefore, we decided that the Plan does 
not have to pre-approve the power seat elevation system (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated abutment  includes modification and 
placement (D6056), abutment supported porcelain/ceramic crown (D6058), extraction, erupted tooth requiring 
removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated 
(D7210), bone replacement graft for ridge preservation - per site (D7953), surgical placement of implant body: 
endosteal implant (D6010), and dental savers plan (D0001) provided on January 26, 2022, to November 11, 
2022. 
 
You asked the Plan to pay for the dental services represented by codes D6056, D0658,D7210, D7953, D6010 
and D0001. You say that you are requesting a reconsideration as you confirmed in January that this dentist was 
in-network. The Plan denied your request. The Plan says these services are not covered under the benefit 
package. 
 
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 pay for the 
prefabricated abutment  includes modification and placement (D6056), abutment supported porcelain/ceramic 
crown (D6058), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including 
elevation of mucoperiosteal flap if indicated (D7210), bone replacement graft for ridge preservation - per site 
(D7953), surgical placement of implant body: endosteal implant (D6010), and dental savers plan (D0001) 
provided on January 26, 2022, to November 11, 2022
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) device.

You asked the Plan to pre-approve a CGM. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for CGMs and related supplies have not been met.

The Plan must follow Medicare rules. The rules say that for coverage of a CGM and related supplies, the enrollee must meet all of the initial coverage criteria listed in the Medicare rules section of this letter.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Specifically, the medical records do not support that the enrollee is insulin-treated nor document that the enrollee has a history of problematic hypoglycemia. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on June 16, 2021, billed with 
codes 95907 and 95927. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes 
 
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 codes 95907 and 95927 is Nerve conduction studies; 1-2 
studies, and Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or 
skin sites, recording from the central nervous system; in the trunk or head. 
 
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 imaging services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found in this case, procedure code 95907 would 
not be reported with pedicle screw stimulation, as are different procedures. Therefore, this procedure cannot be 
verified. Procedure code 95927 could not be verified, as this procedure was not found in medical record. 
 
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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on June 16, 2021, billed with codes 95907 and 
95927.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T7 kyphoplasty. 
 
You asked the Plan to pre-approve T7 kyphoplasty. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty is only covered for certain indications. 
 
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 T7 kyphoplasty. Our reviewer says that 
the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee has a diagnosis of metastatic lung cancer, severe emphysema on home 
oxygen, and osteoporosis on chronic steroids. The enrollee presented with a four-week history of severe back 
pain. There are no imaging studies showing that the fracture is less than 6-12 weeks old. Therefore, the enrollee 
does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T7 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve T7 kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 27, 2022, billed 
with codes 99239 and 99401. 
 
You asked the Plan to pay for the medical services as billed. You say that this claim should be paid in full. The 
Plan denied your request. The Plan says the codes that remain denied 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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the record does not 
document the time spent on the discharge services. CPT code 99401 has a status indicator of N on the 
Physician Fee Schedule, meaning that this service is noncovered by Medicare. Based on this information, we 
decided that Medicare rules for coverage of the medical services as billed have not been met. Therefore, we 
decided that the Plan does not have to pay for the medical services provided on September 27, 2022, billed with 
codes 99239 and 99401.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the EKG provided on November 29, 2022. 
 
You asked the Plan to waive the copayment for the EKG. You say that you should not have been charged 
multiple copayments. 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 $10 
copayment for diagnostic tests and procedures.  
 
 You have been asked to pay a $10 copayment for the EKG. This item/service falls within the outpatient 
diagnostic tests and therapeutic services 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 waive the copayment 
for the EKG provided on November 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 1, 2022, billed 
with codes 81314, 81345 and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported as 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. 
 
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 
November 1, 2022, billed with codes 81314, 81345 and 81272.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says it is unclear if the recommendations that were made from the testing in 2022 were 
followed, or why testing is needed at this time. 
 
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 the testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee had previously been tested in April 2022 for declining memory. Testing was 
also performed in June and August 2022 with a feedback report completed in November. It is unclear why 
neuropsychological testing would need to be re-performed and is therefore not considered medically necessary 
or reasonable. There is no documentation that the recommendations from the previous neuropsychological 
testing were followed. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve neuropsychological testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing - 4 or more teeth per 
quadrant (D4341) x4 provided on December 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told, by the Plan, a week prior to 
treatment that the services would be covered. Your dentist closed his office; therefore, you had to get new x-
rays. You say you should not have to pay for the billed services. 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. This benefit includes the 
requested periodontal scaling and root planing - 4 or more teeth per quadrant (D4341) but is limited to one 
procedure code every three calendar years, per quadrant. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received D4341 upper right and lower right on date of services June 9, 2021, and D4341 upper left 
and lower left on June 16, 2021. Therefore, these benefits were exhausted as of December 19, 2022. Therefore, 
we decided that the Plan does not have to pay for periodontal scaling and root planing - 4 or more teeth per 
quadrant (D4341) x4 provided on December 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services coded as 81162, 81201, 81292, 81295, 
81298, 81307, 81314, 81317, 81321, 81334, 81351 and 81479 provided on August 27, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you believe that the treatment sought is 
medically necessary to treat the enrollee based on the enrollee's medical condition. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. Panel testing should be billed 
using one CPT code 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 laboratory 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. Also, this was an NGS 
panel that was not billed with a single panel code as required. Therefore, we decided that the Plan does not 
have to pay for laboratory services coded as 81162, 81201, 81292, 81295, 81298, 81307, 81314, 81317, 81321, 
81334, 81351 and 81479 provided on August 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services and retainer crown (D2950, D6740) 
provided on December 13, 2022. 
 
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 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 pay for core 
buildup services and retainer crown (D2950, D6740) provided on December 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pneumatic compressor to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve pneumatic compressor. You say that the supplies are medically nessasary. The Plan denied your request. The Plan says this is available in-network.

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 items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve pneumatic compressor to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study. 
 
You asked the Plan to pre-approve a sleep study. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that polysomnography (PSG) is covered when specific 
criteria are met. 
 
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 a sleep study. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found a polysomnogram is not medically 
necessary. It is unclear from the record what kind of polysomnogram is being requested, or why. The clinical 
visit on March 10, 2023, does not mention any symptoms related to sleep, and does not provide an Epworth 
score. The enrollee's primary complaint at that visit was tinnitus. The enrollee does have nonischemic 
cardiomyopathy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213-24 provided on November 1, 2022. 
 
You asked the Plan to pay for procedure code 99213-24. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says payment is included in the global surgery 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for procedure code 99213 is included in the global surgery 
payment for procedure code 11044 provided on November 1, 2022. Separate payment cannot be made for 
procedure code 99213 as the records show that the denied service was related and rendered during the post-
operative period of a global procedure. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99213 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99213-24 provided on November 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87086) provided on October 18, 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 code billed is not covered for the diagnosis billed. 
 
The Plan must follow Medicare rules. Medicare rules say that Urine culture testing is only covered for certain 
diagnosis codes. 
 
We looked at the file and Medicare rules. Diagnosis code C67.9 is not listed as a covered primary diagnosis 
code for the service billed. 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 (87086) 
provided on October 18, 2022.