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

 
We decided that the Plan does not have to pay for procedure codes 84480, 84436, and 84479 billed for date of 
service August 9, 2022.   

You asked the Plan to pay for procedure codes 84480, 84436, and 84479. You say that you disagree with the 
denial. The Plan denied your request. The Plan says payment for codes 84480, 84436, and 84479 is bundled 
into payment for code 84481. 
 
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 84480, 
84436, and 84479 is a column II code to column I code 84481 with a modifier indicator of 0. The column II 
code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 84480, 84436, and 84479 billed 
for date of service August 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 51700 billed for date of service January 17, 
2023, to January 18, 2023.   

You asked the Plan to pay for procedure code 51700. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 51700 is bundled into payment for code 
51703. 
 
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 51700 
is a column II code to column I code 51703 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 51700 billed for date of service January 17, 2023, to January 
18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 21, 2023, by a chiropractor.

You asked the Plan to pay for the physician service. You say that you do not understand why this was denied. You also say that this has been covered in the past. The Plan denied your request. The Plan says this service is not covered when performed by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit provided on March 21, 2023, by a chiropractor.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service February 
26, 2023, to March 4, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary 
and were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is 
invalid for Medicare purposes.  
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code [S9328 is not valid for Medicare purposes. Based on this information, we decided that 
Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code S9328 billed for date of service February 26, 2023, to March 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service January 10, 
2023. 
 
You asked the Plan to pay for procedure code 99233. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99233 is: Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded. 
 
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 99233. Our reviewer says that procedure 
code 99233 does not meet criteria for payment. Our reviewer found that the available documentation does not 
reflect a comprehensive history, examination or medical decision making of high complexity. 
 
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 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99233 billed for date of service January 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that physical and occupational therapy are recommending that the enrollee be admitted to inpatient rehabilitation, and they have mobility limitations due to impaired balance, impaired strength, and impaired functional activity tolerance. The Plan denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical record supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Practitioner services provided on November 8, 2022, billed 
with evaluation and management (EM) code 99232. 
 
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, the CPT Code Manual definition of code 99232 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
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 that the documentation attached does not 
indicate that this visit was an inpatient stay nor does the documentation support that the actual date of service 
was November 8, 2022. There is no history of the inpatient stay nor does the attached documentation have the 
record to support that an evaluation and management was 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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for Practitioner services provided on November 8, 2022, billed with evaluation 
and management (EM) code 99232.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29876 billed for date of service August 11, 
2022. 
 
You asked the Plan to pay for procedure code 29876. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 29876 is bundled into payment for code 29880. 
 
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 29876 
is a column II code to column I code 29880. 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 29876 billed for date of service August 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81294 and 81297 billed for date of service 
August 8, 2022. 
 
You asked the Plan to pay for procedure codes 81294 and 81297. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes 81294 and 81297 are bundled into 
payment for other 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, we have confirmed that code 81294 
is a column II code to column I code 81292. We have confirmed that code 81297 is a column II code to column 
I code 81295. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 81294 and 81297 billed for date of service August 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure codes 96372, 94640, J7614, and 87804 billed for 
March 9, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says 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 96372 and 94640 have an OPPS status 
indicator of Q1(s) and was billed with code 99284, which has an OPPS status indicator of V. Codes 96372 and 
94640 are not separately payable when billed with a code with an OPPS status indicator of V. Billed procedure 
code J7614 has an OPPS status indicator of M. This means that code J7614 is not billable to Medicare. 
 
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 87804 
is a column II code to column I code 0202U with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 96372, 94640, J7614, and 87804 
billed for March 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on April 5, 2023. 
 
You asked the Plan to pay for the dental service. You say that the Plan should cover some of the dental services 
because you were referred by an in-network provider. The Plan denied your request. The Plan says the denial 
of payment for this service is correct, because the consultation is 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation (D9310) provided on April 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 12, 2022, billed with 
codes 81292, 81295, 81298, 81317, 81351, 81406, 81407, 81408 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have billed the services at issue 
correctly. 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 
October 12, 2022, billed with codes 81292, 81295, 81298, 81317, 81351, 81406, 81407, 81408 and 81479.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0367), guided tissue regeneration (D4266), endosteal implant (D6010), bone replacement graft 
for ridge preservation (D7953), and orthodontic retention (D8680) provided on December 27, 2022. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation, guided tissue regeneration, 
endosteal implant, bone replacement graft for ridge preservation, and orthodontic retention. The Plan denied 
your request. The Plan says these services are not covered in your dental benefit. 
 
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 cone 
beam computed tomography (CT) capture and interpretation (D0367), guided tissue regeneration (D4266), 
endosteal implant (D6010), bone replacement graft for ridge preservation (D7953), and orthodontic retention 
(D8680) provided on December 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), gel pads (K0108), and enhanced steering perform unit (K0108). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, gel pads, and an 
enhanced steering perform unit. You say that you would like the K0861 base and all recommended components 
to be reconsidered for coverage. The Plan denied your request. The Plan says although there are three approved 
power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control 
these power options through the joystick. The Plan says that enhanced steering cannot be approved because it is 
already included with the requested expandable controller (E2377). The Plan also says that gel pads (K0108) 
do not serve a medical need and cannot be covered. 
 
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 electronic connection, harness, 
expandable controller, gel pads, and an enhanced steering perform unit. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has a hemiparesis, and has intact right upper extremity strength. The enrollee has adequate 
upper body strength to manage standard power drives. Our reviewer also found that the enhanced driving is 
part of the expandable control. 
 
Medicare rules also say that for equipment to be covered, it must primarily serve a medical purpose. The gel 
pads at issue in this appeal do not serve a purpose that is primarily medical in nature. This item is available to 
the general public and would be helpful even to those who are not sick or injured. 
 
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 electronic connection, harness, expandable controller, gel pads, and an 
enhanced steering perform unit have not been met. Therefore, we decided that the Plan does not have to pre-
approve an electronic connection (E2311), harness (E2313), expandable controller (E2377), gel pads (K0108), 
and enhanced steering perform unit (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
October 14, 2022. 
 
You asked the Plan to pay for procedure codes 87481 and 87653. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says payment for procedure codes 87481 and 87653 is 
included in the payment for procedure code 87801. 
 
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 87481 and 87653 are column II codes to column I code 87801; 
however, 87481 and 87653 were billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 87481 and 87653. Our reviewer says that 
procedure codes 87481 and 87653 do not meet criteria for payment. Our reviewer found that based on the 
medical records provided, there is no documentation that procedure codes 87481 and 87653 were distinct from 
code 87801. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87481 and 87653 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service October 14, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty at T10. 
 
You asked the Plan to pre-approve a kyphoplasty. You say that this procedure is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the medical criteria for a kyphoplasty have not been met. 
 
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 a kyphoplasty. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the compression fracture is not clearly documented to be acute or subacute with documentation 
of the pain for 5-6 months. Additionally, detailed documentation is not evident regarding worsening pain. 
There is no indication of a progression of the body height loss, greater than 25% vertebral body height loss, 
kyphotic deformity, or a severe impact on her daily activities. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty at T10.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve a bone marrow aspirate. You say that this is medically necessary. The Plan 
denied your request. The Plan says the medical necessity for the denied service has not been established after 
clinical review and per the peer-reviewed medical literature. 
 
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 a bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no specific indication provided to support the request for bone marrow 
aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of bone marrow aspirate for this enrollee's medical condition. No compelling rationale is 
presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate (20939).