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

 
We decided that the Plan does not have to pay for the prostate cancer screening (PSA) (G0103) provided on 
August 8, 2023. 
 
You asked the Plan to pay for the PSA. You say that you would like this bill to be paid. The Plan denied your 
request. The Plan says this test is not covered because 12 months had not passed since your last test. 
 
The Plan must follow Medicare rules. Medicare rules say that screening prostate specific antigen tests are 
covered at a frequency of once every 12 months. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a PSA screening was 
previously covered on February 14, 2023. Based on this information, we decided that the frequency limit for 
coverage of the PSA screening has been exceeded. Therefore, we decided that the Plan does not have to pay for 
the prostate cancer screening (PSA) (G0103) provided on August 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84015 and 85018 billed for date of service 
July 7, 2023. 
 You asked the Plan to pay for procedure codes 84015 and 85018. The Plan denied your request. The Plan says 
payment for codes 84015 and 85018 is bundled into payment for code 85025. 
 
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 codes 
84015 and 85018 are column II codes to column I code 85025. 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 84015 and 85018 billed for 
date of service July 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit for evaluation provided on August 16, 2023. 
 
You asked the Plan to pay for the home visit for evaluation. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit for 
evaluation provided on August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the alveoloplasty with extractions (D7311, D7310) and 
the unspecified removable prosthodontic procedure (D5899x2). 
 
You asked the Plan to pre-approve the alveoloplasty with extractions (D7311, D7310) and the unspecified 
removable prosthodontic procedure (D5899x2). You say that you are in need of dental work that is affecting your ability to eat properly. You say you need this dental work immediately. The Plan denied your request. The 
Plan says your benefit for the alveoloplasty with extractions (D7311, D7310) 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, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
alveoloplasty with extractions (D7311, D7310) and the unspecified removable prosthodontic procedure 
(D5899x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration for teeth 13 and 15 described 
by code D4267. 
 
You asked the Plan to pre-approve the services requested under code D4267. You say that this should be 
approved. The Plan denied your request. The Plan says the code requested cannot be approved as it is not 
correct for the intended 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. The Plan covers the services 
requested under code D4267 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 the services requested under code 
D4267. Our reviewer says that the requested service is not coded correctly. Our physician reviewer found the 
issue in this case is the code that was used for this request. D4267 is a code that is associated with a natural 
tooth. Since the teeth were extracted, the usage of this code is incorrect. There are other codes that pertain to an 
area within the mouth rather than a natural tooth that are more appropriate. Based on the information received, 
D4267 is not medically necessary. 
 
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 the services requested under code D4267 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve guided tissue regeneration for teeth 13 and 15 described by 
code D4267.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service August 21, 
2023. 
 You asked the Plan to pay for procedure code 70480. You say that 70480 should be paid as billed because the 
enrollee had multiple exams on the same date of service. The Plan denied your request. The Plan says payment 
for code 70480 is bundled into payment for code 70450. 
 
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 70480 
is a column II code to column I code 70450. 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 code 70480 billed for date of service August 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87491-59 and 87640-59) provided 
August 24, 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 services are not supported by the records. 
 
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 87640 is infectious agent detection by nucleic acid (DNA 
or RNA); Staphylococcus aureus, amplified probe technique. 
 
In this case, we have confirmed that code 87640 is a column II code to column I code 87641; however, 87640 
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 services. Our reviewer found for code 87640, the 
documentation submitted was reviewed and does not meet criteria. The provider reported procedure code with 
appended modifier 59 distinct procedure code to bypass NCCI Edit with CPT 87641. Staphylococcus aureus, 
methicilian resistant, amplified technique includes, staphylococcus aureus. The laboratory report does not 
include documentation to support a separate procedure, and therefore, cannot be verified. Furthermore, for code 
87491, the documentation submitted was reviewed and does not meet criteria. The medical record does not 
include a physician order for Chlamydia trachomatis, as well as laboratory results. 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory services (87491-59 and 87640-59) provided August 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on July 28, 2023, to 
September 08, 2023. 
 
You asked the Plan to pay for the home health services. You say that you are requesting reconsideration stating 
your physicians render medical care for the patients in the facility as requested by the facility you should not be 
penalized for providing medical services to the member that were medically necessary. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home health services 
provided on July 28, 2023, to September 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the ambulatory infusion pump, single or multiple channels, 
electric or battery operated, with administrative equipment, worn by patient (E0781) provided June 30, 2023. 
 
You asked the Plan to pay for  the ambulatory infusion pump. You say that please see attached orders and 
progress notes, review claim again for payment. The Plan denied your request. The Plan says the clinical 
information does not support coverage of an infusion pump under Medicare rules.  
 
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 pay for the ambulatory infusion pump. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee has a significant medical history of G7000 - 
Myasthenia gravis without (acute) exacerbation. The clinical information does not support coverage of an 
infusion pump under Medicare rules. The review has determined that the medical records provided do not show 
that the ambulatory infusion pump meets the requirements listed in the LCD for Medicare coverage. 
 
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 ambulatory infusion pump have not been met. Therefore, we decided that 
the Plan does not have to pay for  the ambulatory infusion pump, single or multiple channels, electric or battery 
operated, with administrative equipment, worn by patient (E0781) provided June 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L2, L3 kyphoplasty with intradiscal injection with 
PMMA (Polymethyl-methacrylate) cement for anterior column support (22514, 22515, 62290, 72295). 
 
You asked the Plan to pre-approve L2, L3 kyphoplasty with intradiscal injection with PMMA. You say that this 
is medically necessary. The Plan denied your request. The Plan says fracture retropulsion with canal 
compromise is a relative contraindication. 
 
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, L3 kyphoplasty with intradiscal 
injection with PMMA. Our reviewer says that you do not meet criteria for coverage. Our physician reviewer 
found detailed documentation is not evident regarding whether both the L2 and L3 compression fractures are 
acute or subacute. Additionally, there is no documentation of a progression of the body height loss, kyphotic 
deformity, or a severe impact on daily activities. Moreover, there is magnetic resonance imaging (MRI) 
corroboration of retropulsion and other plausible causes of 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, L3 kyphoplasty with intradiscal injection with PMMA have not been met. 
Therefore, we decided that the Plan does not have to pre-approve L2, L3 kyphoplasty with intradiscal injection 
with PMMA (Polymethyl-methacrylate) cement for anterior column support (22514, 22515, 62290, 72295).
Appeal type: ER
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 99285. We decided that the Plan does not have to pay 
for procedure code 99053. 
 
You asked the Plan to pay for procedure codes 99053 and 99285 billed for date of service July 16, 2023. You 
say that you disagree with the denial. The Plan says that the service is included in another service provided to 
you at the same time by the same provider. 
 
We decided that the Plan has to pay for procedure code 99285. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan states that code 99285 is included in another service 
provided to you at the same time by the same provider; however, there is no further explanation or 
documentation for this denial. It is not clear to which other service the Plan is claiming code 99285 is included. 
The Plan has not provided any documentation or binding Medicare rules to support that code 99285 is not 
payable as billed. Therefore, we decided that the Plan has to pay for procedure code 99285 billed for July 16, 
2023. 
 
We also decided that the Plan does not have to pay for procedure code 99053. 
 
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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99053 billed for July 16, 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Level IV - surgical pathology, gross and microscopic examination 
(88305) provided May 5, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that your dental appointment turned out to be a 
medical appointment requiring a surgical procedure. You are requesting review of your claim for payment to 
the laboratory. The Plan denied your request. The Plan says that the services received were not authorized and 
not payable. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the laboratory service by a contract provider. The serving laboratory is also an in-
network provider. The file does not show that the Plan provided notice that the laboratory service would not be 
covered. Under Medicare rules, this means the laboratory service is considered approved by the Plan. 
Therefore, we decided that the Plan has to pay for the Level IV - surgical pathology, gross and microscopic 
examination (88305) provided May 5, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve New Push Handle, Assy, Tru-Balance 3, Pair (K0108), 
expandable controller (E2377), harness for upgrade to expandable controller (E2313), and electronic 
connection between wheelchair controller and two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve the items. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the 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 the items. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the items are not medically necessary as the enrollee has adequate strength to manage standard 
power drives and is able to stand and transfer independently; an advanced positioning system is not medically 
necessary.  
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve New Push Handle, Assy, Tru-Balance 3, Pair (K0108), expandable controller (E2377), harness 
for upgrade to expandable controller (E2313), and electronic connection between wheelchair controller and two 
or more power seating system motors (E2311).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the outpatient services on August 8, 2023, 
to August 25, 2023. 
 
You asked the Plan to waive the copayments for the outpatient services. You say that you would like to have 
this claim reviewed to be processed as a claim at a medical center and not a hospital. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for advanced imaging services at outpatient hospital. You must pay a $275 copayment for surgery 
services at outpatient hospital. The provider billed in the amount of $5,992 and the allowed amount is $242.50. 
This is less than the copayment amount. For both dates of service, it's $242.50 + $275 = $517.50. Therefore, 
results in the total cost sharing amount of $517.50. 
 
You have been asked to pay a $517.50 copayment for the outpatient services. This item/service falls within the 
outpatient hospital services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the 
outpatient services on August 8, 2023, to August 25, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
December 6, 2022. 
 
You asked the Plan to pay for the ED services. You say that you have provided the proper documentation and 
would like he claim reprocessed. The Plan denied your request. The Plan says Medicare payment cannot be 
made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on December 
6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 31624 billed for date of service June 17, 
2023. 
 
You asked the Plan to pay for procedure code 31624. You say that you have reported the service at issue 
correctly. The Plan denied your request. The Plan says the available 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 31624 is: Bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; with bronchial alveolar lavage.  
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 31624. Our reviewer says that procedure 
code 31624 does not meet criteria for payment. Our reviewer found that a bronchoscopy is not included in the 
provided documentation. 
 
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 31624 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 31624 billed for date of service June 17, 2023.