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

 
We decided that the Plan does not have to pay for genetic testing (81455) provided on September 14, 2021. 
 
You asked the Plan to pay for [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. 
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 code 81455 is not supported in the medical record. Specifically, the claim did not include a 
valid DEX Z-code for this genetic testing procedure. Based on this information, we decided that Medicare rules 
for coverage of [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"] have not been 
met. Therefore, we decided that the Plan does not have to pay for genetic testing (81455) provided on 
September 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 7, 2022, 
through March 7, 2022. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered because the documentation was not submitted. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the home health services have not been met. An NOA was not submitted for the services. Therefore, we decided that the Plan does not have to pay for the home health 
services provided from January 7, 2022, through March 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (CPT code 64635-RT) 
and each additional facet joint (64636-LT) provided on September 17, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. As the CPT code 64636-RT, 
64636-59, LT, 64636-59, LT and 64636-59, LT was billed an appropriate primary code that is not eligible for 
payment to the same practitioner for the same enrollee on the same date of service; we find that Medicare rule 
for payment for CPT code 64636-RT, 64636-59, LT, 64636- 59, LT and 64636-59, LT has not been met. You 
can find the guidelines on the Medicare website at https://www.cms.gov. CPT 64635-RT and 64635-LT has an 
MUE value of 1 but billed 2 units for both codes. Per the guidelines, we find the Medicare rule for payment of 
this date of service September 17, 2021, claim has not been met. Therefore, we decided that the Plan does not 
have to pay for destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 
(fluoroscopy or CT); lumbar or sacral, single facet joint (CPT code 64635-RT) and each additional facet joint 
(64636-LT) provided on September 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the enclosed wheeled walker with rear seat (E0144) provided 
on June 27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the walker. You say that you feel that this should be covered and the copay 
should be waived. You badly needed this because you cannot walk. The Plan denied your request. The Plan 
says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. 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 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 enclosed wheeled walker with rear seat 
(E0144) provided on June 27, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine-transportation trips. 
 
You asked the Plan to pre-approve additional trips. You say that the requested additional trips are a medical 
necessity for you. The Plan denied your request. The Plan says the routine-transportation benefit has been 
exhausted for the year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine-transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99215) provided on May 6, 2022 
to June 22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth visit. You say that you had 2 appointments by Telehealth since it is 
advised to do so with COVID in the community. You realize your doctor is out of network but if you visit, the 
Plan covers 40 percent of the allowed fee. The Plan denied your request. The Plan says virtual care is not 
covered under Point OF Service with an out of network provider. 
 
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 outpatient office visit (99215) provided on 
May 6, 2022 to June 22, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care, per day (CPT code 99223) provided on 
April 24, 2022. 
 You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Review of the enrollee's history 
search, there is an outpatient claim found with TOB 131. Outpatient claim was billed with Rev Code 762 and 
paid. Per Medicare guidelines, when a patient is in an outpatient facility setting receiving observation care the 
facility should bill accordingly, an physicians should bill matching outpatient observation codes. Therefore, we 
decided that the Plan does not have to pay for initial hospital care, per day (CPT code 99223) provided on April 
24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99202) with a chiropractor to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that your primary care physician is refusing to 
provide a referral. The Plan denied your request. The Plan says you must use network providers to get your 
medical care and services. 
 
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 
an office visit (99202) with a chiropractor to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81227 and 81355) 
provided on January 9, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered 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. The denial for procedure 81355. National 
Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 81355 and 0030U. This 
PTP edit has a modifier indicator of 0, which indicates there are no modifiers that are allowed with this PTP 
code pair. 
 The denial for procedure 81227. National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit 
exists between 81227 and 0030U. This PTP edit has a modifier indicator of 0, which indicates there are no 
modifiers that are allowed with this PTP code pair. Therefore, we decided that the Plan does not have to pay for 
the laboratory services (CPT code(s): 81227 and 81355) provided on January 9, 2021.
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 May 11, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. 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 May 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuroplasty and/or transposition services provided by a 
surgical assistant on February 4, 2022. 
 
You asked the Plan to pay for the surgical assistant services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
 
 In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the neuroplasty and/or transposition 
services provided by a surgical assistant on February 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing (83789) provided on May 9, 
2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not 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 the testing have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the specimen validity testing (83789) provided on May 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CGM and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that you really need the monitor to keep 
track of your diabetes. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. Your request is not medically necessary because your records show 
you do not have either an insulin pump or multiple daily administrations of insulin. You are on a single daily 
long-acting Lantus insulin injection. Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
CGM and supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 16, 2022, billed with 
multiple codes including code 81225. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was necessary and should be 
paid. The Plan denied your request. The Plan says this claim was not billed in accordance with Medicare 
coding guidelines. 
 
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 
June 16, 2022, billed with multiple codes including code 81225.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 88341, 88342, 88360 
and 88381) provided on January 15, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. The CPT codes 88341, 
88342, 88360 and 88381 has a physician Fee Schedule PCTC indicator of 1 and the claim a place of service 
(POS) of 21-Inpatient hospital. The professional interpretation was furnished in the same payment locality from 
where the TC was furnished. The Medicare rule for payment of this claim has not been met as the professional 
interpretation of a diagnostic test must be separately billed with modifier  26 by the interpreting physician. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 88341, 
88342, 88360 and 88381) provided on January 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88312, 88305, 88112) provided on December 
30, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says these codes are 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 CPT code. 
 
We find that CPT codes 88312, 88305 and 88112 are not supported in the medical record. Specifically, these 
codes have a Professional Component / Technical Component indicator of 1. The services were performed in 
an outpatient facility (place of service 22). For this service to be separately payable, the interpreting physician 
must bill these codes separately with modifier 26. 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 (88312, 88305, 88112) provided on December 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); gastrointestinal pathogen (i.e., Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 6-11 targets (87506) provided on August 4, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the records support the billing of this service. 
The Plan denied your request. The Plan says the service was not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that testing for 6-11 pathogens is covered when there is a 
clinical concern for Clostridium difficile colitis, and Clostridium difficile is one of the pathogens being tested. 
 
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 laboratory test was not medically necessary. Our physician reviewer found the provided documentation 
does not indicate that Clostridium difficile was not one of the pathogens tested on the date of service in this 
case. Therefore, the reviewer found that the coverage criteria 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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal 
pathogen (i.e., Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex 
reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-
11 targets (87506) provided on August 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure of the genicular 
nerve (64624). 
 
You asked the Plan to pre-approve a radiofrequency ablation. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 radiofrequency ablation. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the role of genicular nerve blocks and radiofrequency ablation is still being 
considered. The requested service is considered experimental/investigational at this point. 
 
 
  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 radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a radiofrequency ablation procedure of the genicular nerve (64624).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service March 2, 
2022. 
 
You asked the Plan to pay for procedure code 93010. The Plan denied your request. The Plan says payment for 
code 93010 is bundled into payment for code 31500. 
 
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 93010 
is a column II code to column I code 31500. 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 93010 billed for date of service March 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial. 
 
You asked the Plan to pre-approve an SCS trial. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an SCS trial. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found it appears this would be the your third SCS trial and your psychological problems remain. You are not a suitable candidate for another SCS trial. The 
request is deemed 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 an SCS trial have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator (SCS) trial.