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

 
We decided that the Plan does not have to pay for the duplex scan of extremity veins including responses to 
compression and other maneuvers (93970), complete bilateral noninvasive physiologic studies of upper or 
lower extremity arteries (93923), and duplex scan of lower extremity arteries or arterial bypass grafts, complete 
bilateral study (93925) provided on October 24, 2022. 
 
You asked the Plan to pay for duplex scans of arteries. You say that the enrollee is coming to the office for pain 
and discomfort following endovenous laser ablation. The Plan denied your request. The Plan says the provided 
documentation does not support the medically necessity of the services in this case. 
 
The Plan follows Medicare rules. Medicare rules say that noninvasive physiologic studies of the upper or lower 
extremity arteries performed to establish the level and/or degree of arterial occlusive disease, will be 
considered medically necessary if a) significant signs and/or symptoms indicate a high likelihood of limb 
ischemia, and b) the patient is a candidate for invasive therapeutic procedures. 
 
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 duplex scans of arteries. Our reviewer says 
that the requested duplex scans of arteries are not medically necessary. Our physician reviewer found there is 
no documentation of any symptoms that would suggest an arterial duplex exam was necessary and there is no 
discussion in the medical record that an arterial duplex was even considered. There is documentation that the 
enrollee had palpable pedal pulses. There is no suggestion that an abnormal Doppler waveform study exists. As 
there is no indication for the study and it does not appear that the provider was considering obtaining this study, 
coverage cannot be justified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of duplex scans of arteries have not been met. Therefore, we decided that the Plan 
does not have to pay for the duplex scan of extremity veins including responses to compression and other 
maneuvers (93970), complete bilateral noninvasive physiologic studies of upper or lower extremity arteries 
(93923), and duplex scan of lower extremity arteries or arterial bypass grafts, complete bilateral study (93925) 
provided on October 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality test (D0460), the delivery of antimicrobial 
agents (D4381), gingival irrigation (D4921), a diagnostic consult (D9310), medications (D9630), and an 
unspecified procedure (D9999) provided on December 27, 2022, and January 6, 2023. 

You asked the Plan to pay for the dental services. You say that you had an emergency dental situation, and you 
were told to go the provider, and everything would be covered. The Plan denied your request. The Plan says the 
denial of payment for these services is correct, because the pulp vitality test, the delivery of antimicrobial 
agents, gingival irrigation, a diagnostic consult, medications, and an unspecified procedure are not covered by 
the Plan. 
 
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 the pulp 
vitality test (D0460), the delivery of antimicrobial agents (D4381), gingival irrigation (D4921), a diagnostic 
consult (D9310), medications (D9630), and an unspecified procedure (D9999) provided on December 27, 
2022, and January 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation - per quadrant (D4921) provided on 
September 29, 2022. 
 
You asked the Plan to pay for gingival irrigation. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 gingival 
irrigation - per quadrant (D4921) provided on September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 1, 2022, billed 
with codes 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81328, 81335, 81355, and 81408. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81328, 81335, 
81355, and 81408.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99284, 99285, and G2023 billed for June 
29, 2022, to June 30, 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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code.  

We looked at the file and Medicare rules. Billed procedure codes 99284 and 99285 have an OPPS status 
indicator of J2(V). Given that both codes have the V indicator and were billed on the same claim for the same 
date of service without condition code G0, they are not separately payable. Code G2023 has an OPPS status 
indicator of B and is not recognized by OPPS for payment. Therefore, we decided that the Plan does not have 
to pay for procedure codes 99284, 99285, and G2023 billed for June 29, 2022, to June 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient surgery to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an outpatient surgery. You say that you did not feel comfortable with the provider. 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 
an outpatient surgery to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0220) provided on December 21, 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 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 an 
intraoral x-ray (D0220) provided on December 21, 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 August 4, 
2022. 

You asked the Plan to pay for the billed services. You say that the facility is responsible for obtaining prior 
authorization. The Plan denied your request. The Plan says the code is included in the payment for code 99335. 
 
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 code 99496 was billed on the same day as code 99335. If more than one evaluation and 
management service is provided on the same day by the same physician, only one evaluation and management 
service may be reported. The records do not show that the services were unrelated. 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 99496 billed for date of service August 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431), localized delivery 
of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381 x3), 
gingival irrigation  per quadrant (D4921 x4), and drugs or medicaments (D9630 x3) provided on November 
15, 2022. 
 
You asked the Plan to pay for the dental services represented by codes D0431, D4381, D4921 and D9630. You 
say that the provider was on the recommended list by the Plan and was told to only pay $600. You also say that 
the Plan said they would cover the rest and you will not be charged anything additional. The Plan denied your 
request. The Plan says these services are not a covered expense under the plan. Additionally, a review of your 
enrollment call with the Plan and the benefits discussed reveals no inaccurate information was provided. 
 
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 an 
adjunctive pre-diagnostic test (D0431), localized delivery of antimicrobial agents via a controlled release 
vehicle into diseased crevicular tissue, per tooth (D4381 x3), gingival irrigation  per quadrant (D4921 x4), and 
drugs or medicaments (D9630 x3) provided on November 15, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the SelectMDx test (0339U) provided January 10, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that since specimens for your testing are obtained 
during procedures not performed at your office, you are unable to obtain prior authorization and proactively 
inform patients of their individual coverage benefits for our services. The Plan denied your request. The Plan 
says that under Medicare rules the request for SelectMDx is not a covered benefit because this is not a test 
which has met the coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the laboratory service. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has elevated prostate specific antigen (PSA) of 7.23 ng/mL. The enrollee has not 
had a prostate biopsy and does not have prostate cancer. The medical records provided meet the requirements 
listed in the LCD for Medicare for coverage of the SelectMDx test (0339U). NCCN Guideline Version 2022 
Prostate Early Detection, includes the following statement regarding this test: Overall, the panel believes that 
SelectMDx score is potentially informative in patients who have never undergone biopsy, and it can therefore 
be considered in such individuals. 
 
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 been met. Therefore, we decided that the Plan has to 
pay for the SelectMDx test (0339U) provided January 10, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an excision of uvula (42140). 
 
You asked the Plan to pre-approve an excision of uvula. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
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 an excision of uvula. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has obstructive sleep apnea. There is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the requested service. The record provided does not establish the 
medical necessity and reasonableness of the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an excision of uvula have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an excision of uvula (42140).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 88291 billed for date of service September 
23, 2022. 
 
You asked the Plan to pay for procedure code 88291. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 88291 is bundled into payment for code 81405. 
 
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 88291 
is a column II code to column I code 81405. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 code 88291 billed for date of service September 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330), extraction, erupted 
tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if 
indicated (D7210) x2, extraction erupted tooth or exposed root (D7140) x2, consultation (D9310) and 
therapeutic parenteral drug, single administration (D9610) provided on December 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you should not have to pay any extra since your 
provider did not explain the policy to you. 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 D0330 but is limited to one procedure code every five calendar years, D7210 and D7140 but is 
limited to two procedure codes per calendar year. D9310 and D9610 are not covered under the Plans dental 
benefits. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received covered intraoral  
complete series of radiographic images including bitewing (D0210) on November 17, 2022, and extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal 
flap if indicated (D7210) x2 on December 15, 2022. Therefore, these benefits have been exhausted. Therefore, 
we decided that the Plan does not have to pay for panoramic radiographic image (D0330), extraction, erupted 
tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if 
indicated (D7210) x2 and extraction erupted tooth or exposed root (D7140) x2 provided on December 15, 
2022. 
 
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 
consultation (D9310) and therapeutic parenteral drug, single administration (D9610) provided on December 15, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single-photon emission computerized tomography 
(SPECT) scan (78452). 
 
You asked the Plan to pre-approve the SPECT scan. You say that the service is medically necessary. The Plan 
denied your request. The Plan says this request is not medically necessary because the records show the 
enrollee does not have any of the covered indications. The Plan also says the enrollee's most recent stents were 
less than 2 years ago. 
 
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 SPECT scan. Our physician 
reviewer found at issue is the medical appropriateness and necessity of carrying out a radionuclide stress test. 
An echocardiogram performed in February 2023 was unremarkable.  The palpitations reported at a visit in 
December 2022 were no longer present at a recent April 2023 visit, with no reports of any cardiopulmonary 
symptoms, hence the plan to follow-up in 3-4 months, without reference to radionuclide stress testing. There is 
no evidence provided that would support the need for radionuclide stress testing at this time. In summary, there 
is insufficient documentation to support the medical necessity for the requested cardiac stress testing in this 
enrollee's clinical management. 
 
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 SPECT scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a single-photon emission computerized tomography (SPECT) scan (78452).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of residual tooth roots tooth #'s 3 and 16 
(cutting procedure) (D7250). 
 
You asked the Plan to pre-approve removal of residual tooth roots tooth #'s 3 and 16 (cutting procedure). The 
Plan denied your request. The Plan says there are other codes that are more appropriate for the extraction of 
residual roots your provider should have submitted. 
 
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. The Plan covers removal of 
residual tooth roots tooth #'s 3 and 16 (cutting procedure) 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 removal of residual tooth roots tooth 
#'s 3 and 16 (cutting procedure). Our reviewer says that the requested service is not medically necessary. Our 
physician reviewer found tooth #3 appears to be broken down/eroded with minimal bone remaining around the 
roots, making it impossible the tooth could be removed without cutting the bone. #16 appears to be possibly a 
remaining fragment, though vague, and near the surface of the gingiva. It does not appear that cutting of the 
gum and bone would be required to remove the fragment. 
 
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 removal of residual tooth roots tooth #'s 3 and 16 (cutting procedure) have not 
been met. Therefore, we decided that the Plan does not have to the  removal of residual tooth roots tooth #'s 3 
and 16 (cutting procedure) (D7250).