Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image 
(D0230) provided on February 1, 2023. 
 
You asked the Plan to pay for the periodontal scaling and root planing and intraoral - periapical each additional 
radiographic image. You say that you would have not had the procedure had you known it would not be 
covered. The Plan denied your request. The Plan says your benefit for the intraoral - periapical each additional 
radiographic image 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 intraoral - periapical each additional radiographic image was exhausted on date of 
service February 1, 2023. You received the allowed frequency of the radiographic image (D0220) on the 
appealed claim. You received an additional radiographic x-ray image (D0230) at the same visit. Therefore, we 
decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image 
(D0230) provided on February 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that this is medically necessary. The 
Plan denied your request. The Plan says there is no documentation provided to support the expectation the 
enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the Plan approved an elective right shoulder reverse arthroplasty. This is a 
request for inpatient services following this procedure. However, the provided documentation did not reveal the 
enrollee with an unstable condition or high-risk factors that would predict complications or complex aftercare 
in the hospital that would likely cross 2 midnights for this relatively low-risk procedure that is typically 
ambulatory. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81201, 81292, 81295, 81298, 81307, 
81317, 81321, 81334 and 81351) provided on August 31, 2022. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. 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 the laboratory services (81201, 81292, 81295, 81298, 81307, 81317, 81321, 
81334 and 81351) provided on August 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87640, 87511, 87481, 87500) 
provided on February 10, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration for 
services advising given the enrollee's history of chronic urinary tract infection (UTI) and the proprietary nature 
of the test not available from any other laboratory. The Plan denied your request. The Plan says the provider 
did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. 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. The performance of 
multiple (greater than 1) Food and Drug Administration (FDA)-approved/cleared molecular Infectious Disease 
pathogen identification tests on the same date of service (DOS) for the same intended use on the same patient 
sample is considered as one distinct service [1 unit of service]. A panel cannot be unbundled and billed as individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (87640, 87511, 87481, 
87500) provided on February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services (A4556, A4557, A4649, A9279, S1015 
and S8301) provided on February 16, 2023. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
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 codes S8301, S1015 and A9279 have a Status Indicator of I on the Physician Fee 
Schedule. This means that procedure codes S8301, S1015 and A9279 are not valid for Medicare purposes. 
Furthermore, procedure codes A4556, A4557 and A4649, have a status indicator of 'P' on the Centers for 
Medicare & Medicaid Services (CMS) Physician Relative Value File and is always bundled into payment for 
other services not specified and no separate payment is made per Medicare. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services (A4556, A4557, A4649, A9279, S1015 and S8301) provided on 
February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay office visits with therapeutic injections. 
 
You asked the Plan to pay office visits with therapeutic injections. You say that the services received are 
considered preventative medicine and should be covered when performed by an out-of-network provider. The 
Plan denied your request. The Plan says requested provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay office visits 
with therapeutic injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L2 kyphoplasty (22514, 22515). 
 
You asked the Plan to pre-approve L2 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity coverage criteria is not met as the pain is multifactorial with 
multilevel disc disease. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be 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 L2 kyphoplasty. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is not 
evident regarding worsening pain. There is no indication of a progression of the body height loss, kyphotic 
deformity, or a severe impact on daily activities. The enrollee is not clearly documented to have osteoporosis or 
be on treatment for osteoporosis. Moreover, there is magnetic resonance imaging corroboration of retropulsion 
and other plausible causes of back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L2 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L2 kyphoplasty (22514, 22515).
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 February 21, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial. 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 February 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on January 9, 2023, billed 
with procedure codes 76882-26-RT and 76882-26-LT. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim is 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 code 76882-26-RT and 76882-26-LT is Ultrasound, limited, 
joint or other nonvascular extremity structure(s) (eg, joint space, peri-articular tendon[s], muscle[s], nerve[s], 
other soft-tissue structure[s], or soft-tissue mass[es]), real-time with image documentation. 
 
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 radiology services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the medical records provided does 
not include sufficient documentation to validate that the billed services 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 the radiology services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for radiological services provided on January 9, 2023, billed with procedure 
codes 76882-26-RT and 76882-26-LT.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29581 billed for date of service March 1, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the records support medical necessity. The Plan 
denied your request. The Plan says an appropriate modifier was not appended. 

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 29581 is application of multi-layer compression system; 
leg (below knee), including ankle and foot. We find that CPT code 29581 was not billed with a modifier to 
indicate which leg the services were performed on. 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 procedure code 29581 billed for date of service March 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the procedure of total knee replacement could be safely performed with a 
48 hour observational stay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided February 12, 2022, to 
March 13, 2022. 
 
You asked the Plan to pay for the home health services. You say that you submitted medical records for review and feel these services should be covered. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.ed.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 13, 2022. The NOA was not received by the Plan until September 
9, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided February 12, 2022, to March 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22514).  

You asked the Plan to pre-approve kyphoplasty. 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 percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary 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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no trial of a brace for fracture 
treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22514).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator (E1390). 
 You asked the Plan to pre-approve the oxygen concentrator. You say that this equipment is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patient's skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication. 
 
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 oxygen concentrator Our reviewer says that this equipment is not medically necessary. Our physician reviewer found Oxygen saturation readings were reported to be higher than 89% and in-office SpO2 was 98%. There was no record of wheezing.
 
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 oxygen concentrator have not been met.  Therefore, we decided that the Plan 
does not have to pre-approve an oxygen concentrator (E1390).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six additional physical therapy (PT) visits.  
 
You asked the Plan to pre-approve six additional PT visits. You say that the records provided support the need 
for the total number of physical therapy visits requested.  The Plan denied your request. The Plan says the 
services which remain in dispute 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 six additional PT 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 the additional requested therapy is not generally accepted as 
specific and effective therapy for the enrollee's condition beyond what was approved by the Plan. The records 
do not demonstrate that the unique skills of a professional therapist are required to safely and effectively 
provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under 
the supervision of a therapist. The requested services are not part of a maintenance program, and the 
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. The 
enrollee has had extensive prior therapy approved has had instruction in a home exercise program. The 
requested additional therapy sessions do not require ongoing skilled professional therapy beyond what was 
approved by the Plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of six additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve six additional physical therapy (PT) visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 20 physical therapy (PT) visits.  
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee has gait dysfunction 
secondary to deconditioning and complains of low back pain. She requires support assistance for transfer from sitting to standing position and ambulates with caregiver assistance and walker.  The Plan denied your request. 
The Plan says the enrollee has reached a plateau in treatment and has no medical need for additional formal 
therapy. 
 
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 therapy services. 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 the additional requested therapy is not generally accepted as specific 
and effective therapy for the enrollee's condition beyond what was approved by the health plan. The records do 
not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. The requested services are not part of a maintenance program, and the specialized 
skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a 
program to maintain the enrollee's current condition or to prevent or slow further deterioration. 
 
The enrollee has had extensive prior PT. She has had instruction in a home exercise program. The enrollee's 
functional level does not require additional formal therapy. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional 20 physical therapy (PT) visits.