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

 
We decided that the Plan does not have to pre-approve the dental services (D6241(x1), D6791(x1) and 
D6751(x8)). 
 
You asked the Plan to pre-approve the dental services (D6241(x1), D6791(x1) and D6751(x8)). You say that 
you would like to request reconsideration of the denied claim and that the services requested are medically 
necessary. 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 services will be exhausted as the requested services exceed the limits of 
coverage. Therefore, we decided that the Plan does not have to pre-approve the dental services (D6241(x1), 
D6791(x1) and D6751(x8)).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a functional electrical stimulator (FES). 
 
You asked the Plan to pre-approve a FES. You say that the item is medically necessary. The Plan denied your 
request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage of NMES to treat muscle atrophy is limited 
to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and 
peripheral nerves, and other non-neurological reasons for disuse atrophy. 
 
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 FES. Our reviewer says that the item 
is not medically necessary. Our physician reviewer found the records do not document objective findings of 
muscle atrophy/disuse atrophy or spinal cord injury. 
 
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 FES have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a functional electrical stimulator (FES).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Breast Cancer Index testing (81518) billed for date of service June 20, 
2023. 
 
You asked the Plan to pay for Breast Cancer Index testing. You say that this test was medically necessary and 
was reported appropriately. The Plan denied your request. The Plan says that this claim was submitted with an 
incorrect date of service, as the date reported should be the date of specimen collection. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, laboratory services should be reported 
with the date of specimen collection as the date of service. However, there are exceptions to this rule. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Breast Cancer Index testing have been met. Specifically, the specimen in this case was a tissue 
sample which would have been collected during a medically necessary and appropriate hospital stay, and the 
test itself was performed after discharge. It is also likely the sample was stored for some time. Based on the 
documentation provided, one of the exceptions has been met, which means that the appropriate date to report in 
this case would be the date the test was performed. In this case, the correct date is June 20, 2023. Therefore, we 
decided that the Plan has to pay for Breast Cancer Index testing (81518) billed for date of service June 20, 
2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 16, 2023, to March 9, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you would like reimbursement for this dental 
work. The Plan denied your request. The Plan says your annual dental allowance amount 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your annual dental allowance amount was exhausted on date of service March 9, 2023. Therefore, we decided that the Plan does not have to pay any more for dental services provided on February 16, 2023, to 
March 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 2, 2023, billed with 
evaluation and management (EM) code 99212-25. 
 You asked the Plan to pay for the practitioner 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 
code. 
 
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 99212-25 is a column II code to column I code 20610; however, 
99212-25 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 the practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found procedure report does not support the 
patient's condition required a significant identifiable evaluation and management service.  Therefore, this 
procedure 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 the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on May 2, 2023, billed with evaluation and 
management (EM) code 99212-25.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from December 6, 2022, 
to December 15, 2022 at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
DRG 871 billed is correct as the medical record supports the primary diagnosis code A41.9  
(Sepsis unspecified organism). The Plan denied your request. The Plan says the medical records support the 
determination to remove diagnosis code A41.9 (Sepsis unspecified organism) as the primary diagnosis. 
Diagnosis code J10.01, (Influenza due to other identified influenza virus with the same other identified 
influenza virus pneumonia) is sequenced as the new primary diagnosis.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.9 (Sepsis unspecified organism). 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 inpatient hospital services at the DRG originally billed. 
Our reviewer says that the the documentation does not support that the inpatient care is payable as billed. Our 
physician reviewer found the enrollee with a history of COPD was admitted with hypoxic respiratory failure, 
diagnosed with influenza A. The enrollee was tachypneic to 27 and tachycardic to 105. The enrollee had a 
confirmed infection with influenza and met systemic inflammatory response syndrome criteria. The primary 
code should be J10.01 rather than A41.9 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from December 6, 2022, to December 15, 2022 at the DRG originally 
billed.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0151, Q5002) provided on January 
3, 2022, to February 1, 2022. 
 You asked the Plan to pay for home health services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
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 3, 2022. The NOA was not received by the Plan until April 22, 
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 home health services (G0151, 
Q5002) provided on January 3, 2022, to February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99348 for date of service June 15, 2023. 
 
You asked the Plan to pay for procedure code 99348. 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 99348 is home or residence visit for the evaluation and 
management of an established patient, which requires a medically appropriate history and/or examination and 
low level of medical decision making. When using total time on the date of the encounter for code selection, 30 
minutes must be met or exceeded. 
 
We find that CPT code 99348 is not supported in the medical record. Specifically, the claim shows that this 
code was billed with a place of service 02 (telehealth provided other than in patient's home). This is an invalid 
place of service for this service provided. This code is not payable as billed. Based on this information, we 
decided that Medicare rules for coverage of procedure code 99348 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 99348 for date of service June 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided from March 27, 2023. 
 
You asked the Plan to pay for outpatient hospital services. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says there are one or more I/OCE edit 
errors which make this claim unable to be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that services with a status 
indicator of B always return edit 62, which means that the entire claim is returned to the provider for correct. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of outpatient hospital services have not been met. Specifically, code 88187 was reported on this 
claim. Code 88187 has a status indicator of B. This means that edit 62 is returned and the claim is returned to 
the provider for correction. Therefore, we decided that the Plan does not have to pay for outpatient hospital 
services provided from March 27, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a laparoscopic sleeve gastrectomy (43775). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the enrollee saw an exercise fitness 
coach on January 12, 2023. You say that the enrollee currently engages in daily walks and exercise bands, as 
instructed by their coach. You also say that the enrollee will continue this after surgery. The Plan denied your 
request. The Plan says that this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that to be eligible for bariatric surgery the patient must 
have a body-mass index (BMI) at least 35, and at least one co-morbidity related to obesity. Further, the 
documentation must clearly demonstrate the failure of reasonable non-invasive/non-surgical treatments for 
obesity with which the beneficiary has been compliant. 
 
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 surgical procedure. Our reviewer 
says that the requested laparoscopic sleeve gastrectomy is medically necessary. Our physician reviewer found 
the provided documentation indicates that the enrollee's body mass index (BMI) and comorbidities qualify them for the requested procedure. The documentation supports that the enrollee met with an exercise 
physiologist and has been working with a dietitian who noted that on June 12, 2023, that the enrollee has been 
walking more at home and in the store. The documentation also supports a thorough multi-disciplinary 
evaluation for bariatric surgery. Therefore, the reviewer found that the requested laparoscopic sleeve 
gastrectomy is medically reasonable and necessary in this case. 
 
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 surgical procedure have been met. Therefore, we decided that the Plan has 
to pre-approve a laparoscopic sleeve gastrectomy (43775).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 13, 2023, billed with 
codes 87635, 87502, 87503, 87486, 87541, 87581, 87651, and 87798. 
 
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 
June 13, 2023, billed with codes 87635, 87502, 87503, 87486, 87541, 87581, 87651, and 87798.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 for date of service September 8, 2022. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the diagnosis code at issue is not appropriate as a primary diagnosis.  
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code F02.81, defined as 
dementia in other diseases classified elsewhere, unspecified severity, with behavioral disturbance. This code is 
not an appropriate primary diagnosis as the code has a Code first note indicating to code the underlying 
condition first. Based on this information, we decided that Medicare rules for payment of this claim have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 99285 for date of 
service September 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided by a registered nurse first 
assistant (RNFA) on April 10, 2023. 
 
You asked the Plan to pay for surgical assistant services. You say that a surgical assistant is applicable and 
recommended for this procedure. The Plan denied your request. The Plan says this provider is not eligible for 
payment under Medicare. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided 
by a registered nurse first assistant (RNFA) on April 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92979 for date of service April 6, 2023. 
 
You asked the Plan to pay for procedure code 92979. 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 92979 is endoluminal imaging of coronary vessel or graft 
using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) during diagnostic evaluation 
and/or therapeutic intervention including imaging supervision, interpretation and report; each additional vessel 
(List separately in addition to code for primary procedure). 
 
 We find that CPT code 92979 is not supported in the medical record. Specifically, the submitted medical 
records do not indicate that endoluminal imaging of coronary vessel or graft using intravascular ultrasound 
(IVUS) or optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention 
including imaging supervision, interpretation and report; each additional vessel). Based on this information, we 
decided that Medicare rules for coverage of procedure code 92979 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 92979 for date of service April 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical bone growth stimulator (E0747). 
 
You asked the Plan to pre-approve an electrical bone growth stimulator. You say that the requested item is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage of an 
electrical bone growth stimulator have not been met. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for 
nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial 
radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment 
with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days. 
 
In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The file does not 
show that there were 2 or more serial radiographs separated by 90 or more days confirming that healing had 
ceased. 
  Therefore, we decided that the Plan does not have to pre-approve an electrical bone growth stimulator (E0747).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0299, G0300, Q5001) provided on 
June 19, 2022, to July 18, 2022. 
 You asked the Plan to pay for home health services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
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 May 20, 2022. The NOA was not received by the Plan until October 3, 
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 home health services (G0299, 
G0300, Q5001) provided on June 19, 2022, to July 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoscopic rhizotomy procedure (22102). 
 
You asked the Plan to pre-approve an endoscopic rhizotomy. You say that an endoscopic rhizotomy is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says an endoscopic rhizotomy is 
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 an endoscopic rhizotomy. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is insufficient evidence in the published medical literature to determine the safety and 
efficacy of an endoscopic approach (endoscopic dorsal ramus rhizotomy) compared to thermal radiofrequency 
denervation for the treatment of spinal 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 an endoscopic rhizotomy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an endoscopic rhizotomy procedure (22102).