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

 
We decided that the Plan does not have to pay for practitioner services provided on October 24, 2022, billed 
with procedure codes 99497-25 and 90694. 
 
You asked the Plan to pay for the practitioner services provided. You say 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. 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 99497-25 and 90694 is advanced care planning including 
the explanation and discussion of advance directives such as standard forms (with completion of such forms, 
when performed); by the physician or other qualified health care professional; first 30 minutes, face to face 
with the patient, family member(s), and/or surrogate, and Influenza virus vaccine, quadrivalent (allV4), 
inactivated, adjuvanted, preservative free 0.5 mL dosage, for intramuscular use.  
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 codes. Our reviewer found that the documentation does not include 
sufficient documentation to support separate billing of advanced care planning. Code 90694 denied correctly as 
the National Drug Code (NDC) number does not match billing documentation, and therefore cannot be 
verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on October 24, 2022, billed with procedure 
codes 99497-25 and 90694.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling in presence of generalized moderate or severe 
gingival inflammation (D4346) provided on February 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says the enrollee's 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 February 28, 2023. The 
claim for February 28, 2023 was processed prior to the claim for February 14, 2023. Therefore, we decided that 
the Plan does not have to pay for scaling in presence of generalized moderate or severe gingival inflammation 
(D4346) provided on February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96372 billed for January 27, 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 separately paid. 
 
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 code 96372 has an OPPS status indicator of Q1(S) 
and was billed with code 99284, which has an OPPS status indicator of V. Code 96372 is not separately 
payable when billed with a code with an OPPS status indicator of V. Therefore, we decided that the Plan does 
not have to pay for procedure code 96372 billed for January 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seating combination system with mechanical 
shear (E1007) and a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seating combination system with mechanical shear and a power 
seat elevation system. The Plan denied your request. The Plan says the enrollee does not meet the criteria for a 
power seating combination system. The Plan also says the power seat elevation system is non covered because 
it is not primarily medical in nature. 
 
The Plan follows Medicare rules. Medicare rules say that a power seating combination system will be covered 
if the criteria listed in the Medicare rules section of this letter are met. The rules also say that a power seat 
elevation feature (E2300) is non-covered because it is not primarily medical in nature. 
 
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 power seating combination system 
with mechanical shear. Our reviewer says that the enrollee does not meet the criteria for coverage. Our 
physician reviewer found the enrollee does not have high risk for skin breakdown, use a catheter intermittently, 
have spasticity or require an alternative means of managing power drive. 
 
We looked at this physician's review, the file, and Medicare rules. The rules clearly state that a power seat 
elevation system is not medical in nature and cannot be covered. Based on this information, we decided that 
Medicare rules for coverage of a power seating combination system with mechanical shear and a power seat 
elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve a power 
seating combination system with mechanical shear (E1007) and a power seat elevation system (E2300).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to waive the cost sharing for the lab services provided on March 8, 2023. 
 
You asked the Plan to waive the cost sharing for the lab services. You say that these services should have been 
covered in full. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
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. The Plan did not provide the complete 2023 Evidence of Coverage (EOC). 
Therefore, we decided that the Plan has to waive the cost sharing for the lab services provided on March 8, 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet 
joint, radiofrequency ablation (RFA) (64635). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, paravertebral facet joint, radiofrequency 
ablation. You say that this is medically necessary. The Plan denied your request. The Plan says the request is 
not medically necessary because the records show the enrollee did not have at least two diagnostic MBB 
providing a consistent minimum of 80% sustained relief of pain.  
The Plan follows Medicare rules. Medicare rules say that in order for thermal radiofrequency destruction of 
lumbar paravertebral facet joint nerves to be considered medically reasonable and necessary, patients must 
have had at least 2 MBBs, with each providing a consistent minimum of 80% sustained relief of primary pain. 
 
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 destruction by neurolytic agent, 
paravertebral facet joint, radiofrequency ablation. Our reviewer says that the enrollee does not meet criteria for 
coverage. Our physician reviewer found the enrollee did not achieve 80% on both diagnostic blocks as required 
by the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction by neurolytic agent, paravertebral facet joint, radiofrequency 
ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by 
neurolytic agent, paravertebral facet joint, radiofrequency ablation (RFA) (64635).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 0018U and 0245U billed for November 29, 
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 procedure codes 0018U and 0245U 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 0018U is oncology (thyroid), microRNA profiling by 
RT-PCR of 10 microRNA sequences, utilizing fine needle aspirate, algorithm reported as a positive or negative 
result for moderate to high risk of malignancy. The definition of code 0245U is oncology (thyroid), mutation 
analysis of 10 genes and 37 RNA fusions and expression of 4 mRNA markers using next-generation 
sequencing, fine needle aspirate, report includes associated risk of malignancy expressed as a percentage.  
We find that CPT codes 0018U and 0245U are not supported in the medical record. Specifically, the submitted 
records do not match the billed date of service. 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 0018U and 0245U billed for November 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided on February 13, 2023. 
 
You asked the Plan to pay for the radiology services. You say that the diagnoses billed are valid and these 
services were medically necessary. The Plan denied your request. The Plan says you billed this claim with an 
inappropriate pair of diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of R10.9 and N23. Code R10.9 is an Excludes1 code under 
code N23, so these two diagnoses cannot be billed together. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay 
for radiology services provided on February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 76942 billed for date of service January 19, 
2023.  
 
You asked the Plan to pay for procedure code 76942. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 76942 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 76942 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 76942 billed for date of service January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99239 billed for date of service February 18, 2023. 
 
You asked the Plan to pay for code 99239. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says the medical records do not support the billing of this 
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 99239 is Hospital discharge day management: more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, this is a time-based code.  
That means that the medical records must explicitly show that the hospital discharge services lasted longer than 30 minutes. The medical records you provided in support of this code do not show the number of minutes spent 
on this service. Based on this information, we decided that Medicare rules for coverage of code 99239 have not 
been met. Therefore, we decided that the Plan does not have to pay for code 99239 billed for date of service 
February 18, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myrbetriq. 
 
You asked the Plan to pre-approve Myrbetriq. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Myrbetriq.  Benefits for Myrbetriq may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical access to an implant body (second stage 
implant surgery) tooth #27 (D6011). 
 
You asked the Plan to pre-approve the surgical access to an implant body (D6011). The Plan denied your 
request. The Plan says this service 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 surgical access to an implant body 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve surgical access to an implant body (second stage implant surgery) tooth #27  (D6011).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 home ventilator. Our reviewer says 
that the item is not medically necessary. Our physician reviewer found the home ventilator will be used in a 
BiPAP setting/therapy and there is no indication the enrollee has previously failed BiPAP therapy. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 72040, 70100, 70310, 74230, and 74240 
billed for date of service March 7, 2023. You asked the Plan to pay for the billed services. You say that the services were requested for immediate 
evaluation. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim was billed with an office place of service code (11). However, 
the records show the enrollee was in a skilled nursing facility at the time the mobile imaging services were 
provided. There is a more accurate place of service code available. Procedures, such as code 74230 and 74240, 
involving the use of contrast media are not covered under the portable x-ray provision. 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 procedure codes 72040, 70100, 70310, 74230, and 74240 
billed for date of service March 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 13, 2023, billed 
with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81238 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was necessary and is supported in 
the medical record. 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 
February 13, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335, 81238 and 81479.
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 previously the enrollee was an independent, high 
functioning person who lives alone. You say the enrollee's care team recommends this intense therapy. The 
Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for services in 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 pre-approve a repeat epidural steroid injection (ESI). 
 
 You asked the Plan to pre-approve a repeat ESI. You say that the enrollee responded extremely well to the first 
epidural steroid injection and one more would likely treat the now episodic pain flares they are experiencing.  
The Plan denied your request. The Plan says the repeat epidural steroid injection you are requesting does not 
meet the requirements for approval.  
 
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 repeat ESI. Our reviewer says that the 
requested repeat epidural steroid injection is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the LCD rule requires 50% pain relief for three months. This was not achieved 
and therefore, the request is deemed not medically reasonable and 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 a repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI).