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

 
We decided that the Plan does not have to pay for the services provided on July 27, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
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 services at issue were reimbursed 
by the Plan on August 25, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that 
the Plan does not have to pay for the services provided on July 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 93882 billed for date of service October 7, 
2022. 
 You asked the Plan to pay for procedure code(s) 93882. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says this code is included in the facility payment and is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 93882. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 93882. Based on this information, 
we decided that Medicare rules for coverage of procedure code 93882 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 93882 billed for date of service October 7, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (82607, 84436, 84443) provided on June 6, 
2022. 
 
You asked the Plan to pay for laboratory testing. You say that you disagree with the denial. You have attached 
medical records and are requesting reprocessing of the claim. The Plan denied your request. The Plan says this 
is an administrative determination for non-coverage and is not based on clinical criteria for medical necessity. 
The services are not authorized because, they are not a Medicare benefit for the diagnoses listed on the claim 
and are done for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, laboratory testing, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
laboratory testing (82607, 84436, 84443) provided on June 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (82247, 82947, 84450, 84460) provided on 
August 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says these services are not covered because they were provided OON without 
prior authorization. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the lab services (82247, 82947, 84450, 84460) 
provided on August 4, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment received on August 16, 2022. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are in-network providers within a reasonable distance. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for oxygen equipment received on August 16, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies (K0553) provided on 
August 18, 2022. 
 
You asked the Plan to pay for the CGM supplies. The Plan denied your request. The Plan says that a decision 
was not made within the time frame. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We looked at the file, and Medicare rules. As the case file shows that the plan would have overturned these 
services if they had made the decision in time, the records support the services billed. The criteria for coverage 
of the requested CGM supplies are met. Based on this information, we decided that Medicare rules for 
coverage of the supplies have been met. Therefore, we decided that the Plan has to pay for the continuous 
glucose monitor (CGM) supplies (K0553) provided on August 18, 2022.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A6212 and A6219 billed for date of service 
June 10, 2022. 
 
You asked the Plan to pay for procedure codes A6212 and A6219. You say that these services were necessary 
and should be paid. The Plan denied your request. The Plan says procedure codes A6212 and A6219 is considered bundled and not separately payable. Would care supplies are not separately billable and would be 
included in the bundled payment to the skilled nursing facility. 
 
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 codes A6212 and A6219 both have a status indicator of P on the Physician Fee 
Schedule. This means that procedure codes A6212 and A6219 are not separately payable. Based on this 
information, we decided that Medicare rules for coverage of procedure codes A6212 and A6219 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes A6212 and A6219 billed for 
date of service June 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 87481, 87641, 87651, 87653 
and 87798 provided August 16, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that this test is a Medicare covered service and 
was ordered by a treating physician who makes the professional determination of diagnosis and medical 
necessity to successfully treat their patients. The Plan denied your request. The Plan says the service does not 
meet the coverage requirements in the applicable Local Coverage Determination (LCD) or National Coverage 
Determination (NCD) provided August 16, 2022.  
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 laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a wound PCR test, or polymerase chain reaction test, is a diagnostic test used to 
analyze the cause of a viral infection. A PCR test analyzes a short sequence of DNA from a small sample that 
is harvested from your infected wound. In this case, there was no specific clinical rationale for the requested 
laboratory tests. The review has determined that the items/services at issue in this case were 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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services coded as 87481, 87641, 87651, 87653 and 87798 provided 
August 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (83540, 82728, 80053, 83001, 84439, 
84443, 84466, 85025, G0463) provided on October 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says these services were ordered/provided by an out-of-network provider. 
Out-of-network care is covered only in certain limited circumstances which have not been met in this case. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services (83540, 82728, 80053, 83001, 
84439, 84443, 84466, 85025, G0463) provided on October 6, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 CDx diagnostic services provided on July 
28, 2021. 
 
You asked the Plan to pay for the Guardant360 CDx diagnostic services. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the claim for this molecular pathology testing did 
not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the Guardant360 CDx 
diagnostic services have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 CDx diagnostic services provided on July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation (D7953 
x 2), infiltration of sustained release therapeutic drug (D9613) and therapeutic parenteral drugs, two or more 
administrations, different medications (D9612). 
 
You asked the Plan to pre-approve the dental services. You say that your provider informed you these teeth 
must be removed. The Plan denied your request. The Plan says these services are not covered by the Plan's 
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, 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 
bone replacement graft for ridge preservation (D7953 x 2), infiltration of sustained release therapeutic drug 
(D9613) and therapeutic parenteral drugs, two or more administrations, different medications (D9612).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 1, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment 
for code 70496.  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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service October 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional units of 36248 and 75774 rendered to the enrollee 
on July 25, 2022. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records submitted do not indicate that two separate services were performed/supported. 
 
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. 
 
We looked at the file and Medicare rules. The provider did not send in any evidence that multiple services were 
provided in this case. The denied services appear to be a duplicate. Based on this information, we decided that 
there is insufficient information in the record to determine if Medicare rules for coverage of the services have 
been met. Therefore, we decided that the Plan does not have to pay for additional units of 36248 and 75774 
rendered to the enrollee on July 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed for date of 
service April 12, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653 and 87798. You say that these services are 
supported in the medical record. The Plan denied your request. The Plan says the payment for these codes is 
included in the payment for codes 87150 and 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that codes 87481 and 87653 are both column II codes to column II codes 
87150 and 87801. These two services have not been billed with an appropriate modifier to bypass the edit. 
Based on the claim submitted, Medicare billing criteria have not been met for codes 87481 and 87653. In 
addition, we have confirmed that code 87798 is a column II code to column I code 87150 and 87801; however, 
87798 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 procedure code 87798. Our reviewer says that the use of the 
91 modifier is not supported in this case. Our reviewer found the medical record does not include 
documentation of a repeat laboratory test, and therefore this modifier cannot be verified. This procedure would 
be inclusive to CPT codes 87150 and 87801, as a distinct separate service 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 procedure codes 87481, 87653 and 87798 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed for date of 
service April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) 
(81292) provided on May 30, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory service. You say that this letter and attached documents support 
the medical necessity of the test requested and addresses the place of service denial. The Plan denied your 
request. The Plan says the records do not support the service billed and enrollees must receive their medical services from an in-network providers. Non-emergent services with non-contracted providers require prior 
authorization before services being rendered. 
 
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 at issue in this case is not a network provider with the Plan. 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 laboratory service. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found MLH1 is part of 
panel to look for microsatellite instability (MSI) screening. In non-small cell lung cancer, immunotherapy is 
dictated by programmed cell death ligand 1 (PDL1) status and not MSI status. MSI will not be used to guide 
therapy in lung cancer. thus deny MLH1 as 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 laboratory service have not been met.  
 
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 pay for the laboratory service. Therefore, we decided that the Plan 
does not have to pay for MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (81292) provided on 
May 30, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies provided on June 13, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the documentation submitted did not sufficiently support 
the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The documentation provided did not sufficiently support the billed supply code. 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 the electrical stimulator supplies provided on June 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313) and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested power options are 
covered by Medicare and necessary for the enrollee. The Plan denied your request. The Plan says although 
there are three requested power options, there is not a medical need to control these power options through the 
joystick. The enrollee is noted to have 3/5 strength in the right upper extremity and his upper limb strength and 
function are adequate to control the power options using their own switches which are included in the 
allowance of these power options. These items or services still do not meet the coverage criteria. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require non-proportional input devices (e.g., sip and puff, head 
array, etc.). The enrollee does not require a separate display (i.e., for alternate control devices), other electronic 
devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an 
attendant control. The documentation does not support that it is medically necessary to control the requested 
power options through the joystick (drive interface). The enrollee's upper extremity strength and functional 
ability as evidenced by being independent for feeding should be sufficient to control any power options through 
their own switches. The documentation does not reveal that the requested items are 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 wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313) and an expandable controller (E2377).