Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit system (K0108). 
 
You asked the Plan to pre-approve wheelchair accessory. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the requested transit system kit is solely used to strap the wheelchair to a 
vehicle to travel outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a transit system (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management (EM) services provided on 
January 20, 2023, billed with code 99214-25. 
 
You asked the Plan to pay for the EM services as billed. You say that this should be paid as billed.  The Plan 
denied your request. The Plan says it was determined that payment should made for all services except for 
99214, as the use of the modifier was not clinically appropriate.  
 
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 99214 is a column II code to column I code 96413; however, 99214 
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 EM services as billed. Our reviewer says that the record 
does not include sufficient documentation to support the use of modifier -25 for separate payment.  Our 
reviewer found the enrollee presented to the provider for intravenous Simponi Aria administration services. 
While the note does document worsening psoriasis, this is being followed by dermatology. There was 
insufficient documentation to support that a separate, identifiable EM service took place during this visit.  
 
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 EM services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the evaluation and management (EM) services provided on January 20, 2023, 
billed with code 99214-25.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43235 billed for date of service February 7, 
2023. 
 
You asked the Plan to pay for procedure code 43235. You say that these services were necessary and were pre-
approved. The Plan denied your request. The Plan says it is not medically necessary for this service to be 
performed with an assistant surgeon. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 43235. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for 
procedure code 43235 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 43235 billed for date of service February 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87651, 87680, 86738, and 87500 billed for 
April 13, 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 procedure codes 87651, 87680, 86738, and 87500 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 87651 is infectious agent detection by nucleic acid (DNA 
or RNA); Streptococcus, group A, amplified probe technique. The definition of code 87680 is antibody; Treponemia pallidum. The definition of code 86738 is antibody; mycoplasma. The definition of code 87500 is 
infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species 
van A, van B), amplified probe technique. 
 
We find that CPT codes 87651, 87680, 86738, and 87500 are not supported in the medical record. Specifically, 
there is no documentation of infectious agent detection by nucleic acid for Streptococcus, group A, with 
amplified probe technique to support code 87651. There is no documentation of Treponema pallidum antobody 
testing to support code 86780. There is no documentation of mycoplasma antibody testing to support code 
86738. There is no documentation of infectious agent detection by nucleic acid for vancomycin resistance with 
amplified probe technique to support code 87500. 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 codes 87651, 87680, 86738, and 87500 billed for April 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87798, 87653, 87651) provided on March 29, 
2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT codes 87798, 87653, & 87651 are not supported in the medical record. Specifically, multiple 
unbundled codes were submitted for a single panel. Based on this information, we decided that Medicare rules 
for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for 
lab services (87798, 87653, 87651) provided on March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ESI. 
 
You asked the Plan to pre-approve the ESI. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the criteria for coverage 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 the ESI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the radiological image-based diagnostic testing does not support one lumbar radiculopathy, 
radicular pain and/or neurogenic claudication due to disc herniation, osteophyte or osteophyte complexes, 
severe degenerative disc disease, producing foraminal or central spinal stenosis or post-laminectomy syndrome. 
The documentation does not reveal evidence of acute herpes zoster associated pain. Therefore, the criteria for 
coverage have not been met.   
 
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 ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an ESI.
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 the services are medically necessary for the enrollee 
to regain their maximum function. The Plan denied your request. The Plan says the services are not medically 
necessary.  
 
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 is medically stable. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the accessory bar, polyurethane liner, cushion cover. 
 
You asked the Plan to pre-approve accessory bar, polyurethane liner, cushion cover. You say that this power 
wheelchair is medically necessary for the enrollee. The Plan denied your request. The Plan says these items are 
not primarily medical in nature and therefore are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the accessory bar, polyurethane liner, cushion cover.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 22, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 22, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the parenteral nutrition billed with codes B4199, B4220 and B4224 for 
date of service March 24, 2023, to March 29, 2023. 
 
You asked the Plan to pay for the parenteral nutrition. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the submitted medical records don't include a compounding sheet 
or a mixing report, which is required in order to support the billed charges. 
 
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 rules also state that DMEPOS is covered only when there are both a physician order and proof of 
delivery. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the Plan is denying these codes due to the 
submitted medical records don't include a compounding sheet or a mixing report, which is required in order to 
support the billed charges. In addition, the Plan states there is not a valid physician order. The documentation 
did not include Medicare rules to show that a compounding sheet or a mixing report was required. In addition, 
the documentation included a valid refill request and a pharmacy work order/compounding record. No other 
denial rationale was provided. The record does contain a valid physician order and proof of delivery. Review of 
the file does not reveal any reason that the required documentation is invalid. The Plan did not substantiate 
their denial. Therefore, we decided that the Plan has to pay for the parenteral nutrition billed with codes B4199, 
B4220 and B4224 for date of service March 24, 2023, to March 29, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99232, 99233, and 99153 billed for 
December 12, 2022, to December 14, 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. 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 inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded. The 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 physician 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 these services. Our reviewer says that procedure codes 
99232 and 99233 are not supported. Our reviewer found the records support a comprehensive examination but 
not a comprehensive history or medical decision making of high complexity to support code 99233. There is no 
comprehensive history or medical decision making of moderate complexity to support code 99232. 
 
The rules say that a professional component (PC)/technical component (TC) indicator of 3 identifies technical 
component only stand alone codes. 
 
Billed procedure code 99153 has a PC/TC indicator of 3 and no separate PC payment. 
 
We looked at this physician's review, the file, and Medicare rules. 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 codes 99232, 99233, and 99153 billed for December 12, 2022, to December 14, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 16, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (Tdap) vaccine 
and its administration received on April 17, 2023. 
 
You asked the Plan to pay for the Tdap vaccine. You say that you would have declined the vaccination if you 
had known the cost and that it may not be covered by your Part C plan. The Plan denied your request. The Plan 
says that its original determination was correct. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine. 
Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis 
(Tdap) vaccine and its administration received on April 17, 2023.  
 Your complaint about your provider not telling you the cost and that it may not be covered is not a valid appeal 
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare 
does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional complete bilateral noninvasive physiologic 
studies of upper or lower extremity arteries (93923-76-51) provided on January 13, 2023. 
 
You asked the Plan to pay for the additional complete bilateral noninvasive physiologic studies. You say that 
this is a claim that is clearly medically necessary and indicated based on diagnosis and proper management of 
this patient to be processed for payment. The Plan denied your request. The Plan says this claim is a duplicate 
of a previously paid claim and was correctly denied. The Plan also says there is no documentation that a repeat 
procedure was performed. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 15, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the additional complete bilateral noninvasive 
physiologic studies have not been met. Therefore, we decided that the Plan does not have to pay for the 
additional complete bilateral noninvasive physiologic studies of upper or lower extremity arteries (93923-76-
51) provided on January 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service April 14, 2023. 
 
You asked the Plan to pay for the billed services. You say that the test was ordered due to its validated clinical 
utility. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
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 the panel testing was not billed with a single code as required. 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 the lab testing billed for date of service April 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6750 x2) and pontic (D6240). 
 
You asked the Plan to pre-approve a retainer crown and pontic. You say that the services are necessary. The 
Plan denied your request. The Plan says the retainer crown is not a covered benefit. Because the pontic is 
connected to the approval of the denied retainer crown, the pontic is not covered.  

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 pre-approve a 
retainer crown (D6750 x2) and pontic (D6240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140), intraoral 
- periapical first radiographic image (D0220), and each additional radiographic image (D0230) provided on 
January 11, 2023, to February 2, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D0140, D0220 and D0230. You say that 
you and the provider were advised by the plan that the provider was in-network prior to the services being 
rendered. You also say that you do not feel the provider should be held responsible. The Plan denied your 
request. The Plan says the limited oral evaluation is not covered. The Plan also says that the intraoral - 
periapical first radiographic image and intraoral  periapical additional radiographic images 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 limited oral evaluation - problem 
focused (D0140) are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the limited oral evaluation - problem focused (D0140) provided on January 11, 2023. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The 
documentation provided by the Plan states that they paid for an intraoral radiographic imaging code provided 
on January 24, 2023, under claim ending in 0145. This means that the benefit for intraoral images was 
exhausted for the 2023 calendar year. Therefore, we decided that the Plan does not have to pay for the intraoral 
- periapical first radiographic image (D0220), intraoral  periapical additional radiographic images (D0230x2) 
provided on January 11, 2023, to February 2, 2023.