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

 
We decided that the Plan does not have to pay for procedure code J3490 billed for date of service September 
26, 2023. 
 
You asked the Plan to pay for the billed code. You say that the drug was a necessary part of treatment. The 
Plan denied your request. The Plan says the code cannot be separately reimbursed. 
 
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 J3490 is unclassified drugs. We find that CPT code J3490 
is not supported in the medical record. Code J3490 was billed for local anesthetic drug Bupivacaine. The use of 
local anesthesia is not separately billable. Based on this information, we decided that Medicare rules for 
coverage of the billed code have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code J3490 billed for date of service September 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM), supplies and 
accessories provided on June 27, 2023. 
 
You asked the Plan to pay for the CGM, supplies and accessories. You say to please review the submitted 
medical records that we have already submitted with all the required documents. You also say that the 
insurance still denied the claim because of missing/incomplete documents (Proof of Delivery). The Plan denied 
your request. The Plan says the provider is not a plan contract provider and is not enrolled in Medicare as a 
durable medical equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM), 
supplies and accessories provided on June 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71250) 
to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a CT scan of the chest with an out-of-network provider. You say that you 
want the Plan to approve the service. The Plan denied your request. The Plan says the requested provider is out-
of-network. The service at issue is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
   
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a computed tomography (CT) scan of the chest (71250) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skin grafting (15271 and Q4253) provided on August 2, 
2023.  
 
You asked the Plan to pay for 15271 and Q4253. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this claim was submitted with the frequency code of 8 which is used to 
void/cancel a claim. 
 
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 15271 is application of skin substitute graft to trunk, 
arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area. The CPT Code 
Manual definition of code Q4253 is zenith amniotic membrane, per square centimeter. 
 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 15271 and Q4253. Our reviewer says that these codes do not 
meet criteria for payment. Our reviewer found although the procedure codes are supported in the medical 
record, the frequency code of 8 (claim is a voided/cancelled claim) was incorrectly billed and should be 
corrected. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 15271 and Q4253 have not been met. Therefore, we decided that the Plan does 
not have to pay for skin grafting (15271 and Q4253) provided on August 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the specialist office visits, the x-rays, and 
the triamcinolone acetonide injection provided on May 8, 2023, and June 28, 2023. 
 
You asked the Plan to waive the cost share for the specialist office visits, the x-rays, and the injection. You say 
that you disagree with the cost share. 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 $40 
copayment for each out-of-network Medicare-covered specialist visit. Your contract with the Plan also clearly 
says that you must pay 40% coinsurance for each out-of-network Medicare-covered x-ray. Your contract with 
the Plan also clearly says that you must pay 40% coinsurance for out-of-network Medicare-covered drugs and 
administration.  
 
You have been asked to pay $40 copayment for each specialist office visits provided on May 8, 2023, and June 
28, 2023. These services fall within the physician/practitioner services, including doctors office visits 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.  
 
You have also been asked to pay $22.08, which is 40% coinsurance of the allowed amount for each x-ray 
provided on May 8, 2023 ($55.21 allowed amount x 40% = $22.08). These services fall within the outpatient 
diagnostic tests and therapeutic services and supplies visits benefit category. You have also been asked to pay 
$7.18, which is 40% coinsurance of the allowed amount for the injection provided on June 28, 2023 ($17.96 
allowed amount x 40% = $7.18). This service falls within the Medicare Part B prescription drugs visits 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 cost share for the specialist office visits, the x-rays, and the 
triamcinolone acetonide injection provided on May 8, 2023, and June 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT scan) guidance for needle 
placement and monitoring billed with codes 77012 and 77013 provided on March 2, 2023. 
 
You asked the Plan to pay for the CT scan. You say that the services were billed correctly and should be paid. 
The Plan denied your request. The Plan says the documentation does not support codes 77012 and 77013. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.    
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 CT scan. Our reviewer says that code 
77012 was billed with modifier -59 to indicate that it is a separate procedure from code 77013, however the CT 
scan for needle placement was performed as part of the tissue ablation. In this case, documentation does not 
support separate payment for the procedure.  
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pay for the computed tomography (CT scan) guidance for needle placement and monitoring billed with 
codes 77012 and 77013 provided on March 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for apolipoprotein, each (82172) lipoprotein (A) (83698) 
measurement of lipoprotein-associated phospholipase A2 (83695) provided August 14, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that you re an independent laboratory and do not 
have access to full patient medical records as you do not see or treat patients but are only sent specimens from 
the ordering physicians. The Plan denied your request. The Plan says the tests performed for Apolipoprotein 
(82172), Lipoprotein (83695), and Lipoprotein-associated phospholipase A2 (83698) are not covered when 
they are included in a cardiovascular risk assessment panel. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay 
for apolipoprotein, each (82172) lipoprotein (A) (83698) measurement of lipoprotein-associated phospholipase 
A2 (83695) provided August 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connection. 
 
You asked the Plan to pre-approve the electronic connection. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is not a medical need to control these power options through the 
joystick. 
 
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 electronic connection. Our reviewer 
says that the requested electronic connection is not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation indicates that the enrollee has adequate strength to 
manage standard power drives. Therefore, the reviewer found that the requested electronic connection is not 
medically reasonable or 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 electronic connection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the electronic connection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation and cone beam computed 
tomography (CT) scan (D0140, D0364) provided on August 29, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for limited oral evaluations has 
already been exhausted. Coverage for the cone beam CT scans denied correctly as they do not fall within your 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 benefit for limited oral evaluations was exhausted on date of service August 21, 2023 (D0140). 
Coverage for the cone beam CT scans denied correctly as they do not fall within your dental benefits. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation and cone beam computed 
tomography (CT) scan (D0140, D0364) provided on August 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99221 billed for date of service June 28, 
2023. 
 
You asked the Plan to pay for the billed code. You say that medical records were provided. The Plan denied 
your request. The Plan says the accuracy of the claim cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that CPT code 99221 is not supported in the medical record. The records submitted are for services 
provided on June 29, 2023. The case file does not include records for the date of service at issue. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99221 billed for date of service June 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
September 13, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service September 13, 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 the enrollee needs ongoing medical supervision by a 
rehabilitation physician at least 3 days a week to maximize recovery. The Plan denied your request. The Plan 
says based on Medicare guidelines, the IRF services requested do not meet the requirements for approval.  
 
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 clinical documentation does not specify any active medical comorbidities or 
complex functional impairments (other ortho-rehabilitation diagnosis) thus the complexity of the enrollee's 
documented nursing, medical and rehabilitation needs would not be expected to require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. Clinical documentation supports 
ongoing physical and occupational therapy but does not justify an intensive rehabilitation regimen in an IRF 
setting. IRF criteria is not 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 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 pay for a continuous glucose monitor (CGM) (A4239) provided on 
July 7, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as the rendering provider is not 
enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) 
(A4239) provided on July 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87635) provided on August 11, 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 coverage criteria has not been met. 
 
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 87635 is Infectious agent detection by nucleic acid (DNA 
or RNA); severe acute respiratory syndrome coronavrius 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), 
amplified probe technique. 
 
We find that CPT code 87635 is not supported in the medical record. Specifically, no physician order was 
provided to support this test. 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 (87635) 
provided on August 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0452 billed for date of service August 14, 
2023. 
 
You asked the Plan to pay for procedure code G0452. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says this code is not supported in the medical 
record. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. The rules also say that providers must report services correctly. In this case, 
we have confirmed that the CPT Code Manual definition of code G0452 is molecular pathology procedure; 
physician interpretation and report. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of procedure code G0452 have been met. 
Specifically, no records were provided to show that a separate physician performed an interpretation and report 
for the lab services provided. Therefore, we decided that the Plan does not have to pay for procedure code 
G0452 billed for date of service August 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-rays and core buildup services (D0220, D0230, 
D2950) provided on August 17, 2023, to August 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 17, 2023. 
Therefore, we decided that the Plan does not have to pay for intraoral x-rays and core buildup services (D0220, 
D0230, D2950) provided on August 17, 2023, to August 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) provided on May 3, 
2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
 The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. The written order was not provided by the treating physician. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) provided on 
May 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 23, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that 99100 should be paid as billed because it 
has been coded accurately and is supported in the documentation. The Plan denied your request. The Plan says 
procedure code 99100 is considered bundled and not separately payable.  
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 58660 billed for date of service May 19, 
2023.  
 
You asked the Plan to pay for procedure code 58660. You say that the records show medical necessity. The 
Plan denied your request. The Plan says payment for code 58660 is bundled into payment for code 57425. 
 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 58660 
is a column two code to column one code 57425 with a modifier indicator of 0. The column two 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 58660 billed for date of service May 19, 2023.