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

 
We decided that the Plan does not have to pay for procedure codes 87150, 87798, and 87641 billed for date of 
service August 9, 2022. 
 
You asked the Plan to pay for procedure code 87150, 87798, and 87641. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says payment for code 87150 is 
bundled into payment for code 87500. Payment for code 87798 is bundled into payment for code 87801. 
Payment for code 87641 is bundled into payment for code 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 code 87150 
is a column II code to column I code 87500. We have confirmed that codes 87798 and 87641 are column II 
codes to column I code 87801. This claim has not been billed with an appropriate modifier to bypass the edit as 
the records do not support that a repeat clinical laboratory test was performed. 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 codes 87150, 87798, and 87641 billed for date of service August 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for application of a skin substitute graft to trunk, arms, legs 
(15271) and Skin substitute, Integra Meshed Bilayer Wound Matrix, per square centimeter (C9363) provided 
December 20, 2021. 
 
You asked the Plan to pay for the outpatient surgery. You say that please review the following medical records 
to reconsider denial codes 15271 and C9363 for medical necessity. You believe these services were appropriate 
based on past medical history. The Plan denied your request. The Plan says this service is considered 
experimental and investigational.  
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 outpatient surgery have not been met. Therefore, we decided that the Plan does not have to pay 
for application of a skin substitute graft to trunk, arms, legs (15271) and Skin substitute, Integra Meshed 
Bilayer Wound Matrix, per square centimeter (C9363) provided December 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 29, 2021, billed with 
codes 81240 and 81241. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. 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 
June 29, 2021, billed with codes 81240 and 81241.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services coded 84480, 80050, 80061, 84153, and 84439 
provided on May 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. The Plan also 
says that payment for code 84480 is bundled into payment for code 84481. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. 
 
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 84480 
is a column II code to column I code 84481 with a modifier indicator of 0. The column II 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 lab services coded 84480, 80050, 80061, 84153, 
and 84439 provided on May 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing evaluation (96132). 
 
You asked the Plan to pre-approve neuropsychological testing. You say that the enrollee needs this. The Plan 
denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that these diagnostic tests are used when mental illness is 
suspected, and clarification is essential for the diagnosis and the treatment 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 pre-approve neuropsychological testing. Our 
reviewer says that the requested neuropsychological testing is not medically necessary. Our physician reviewer 
found the provided documentation does not indicate the intended purpose of the requested testing. The 
reviewer found that the request for the testing is for clarification of diagnosis and treatment planning. The 
reviewer found that this testing is not required for this but rather can be done through an evaluation. Therefore, 
the reviewer found that the requested testing is not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing evaluation (96132).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound infection panel provided on April 27, 2022. 
 
You asked the Plan to pay for the wound infection panel. You say that the provided wound infection panel was 
medically necessary. The Plan denied your request. The Plan says they were unable to make a determination 
within the allotted time frame. 
 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 wound infection panel. Our reviewer 
says that the provided wound infection panel was not medically necessary. Our physician reviewer found the 
review indicates that the enrollee has a venous stasis ulcer on the right leg. In this case, there is no specific 
clinical rationale for the requested laboratory test. The review has determined that the enrollee does not meet 
the LCD criteria for the provided wound infection panel. 
 
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 wound infection panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the wound infection panel provided on April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation system (CPT code E2300), 
expandable controller, including all related electronics and mounting hardware, upgrade provided at initial 
issue (E2377), electronic connection between wheelchair controller and two or more power seating system 
motors (E2311) and harness for upgrade to expandable controller (E2313). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
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 DME have not been met. The notes do not show a medical need 
to control the power options through the joystick. The power options can be controlled using their own 
switches. These switches can be made any size without asking for a separate request. They can be made from 
any material without asking for a request. All of this can be done without the need to use the joystick to control 
the power features. The seat lift does not service a medical purpose and cannot be covered. Therefore, we 
decided that the Plan does not have to pre-approve power seat elevation system (CPT code E2300), expandable 
controller, including all related electronics and mounting hardware, upgrade provided at initial issue (E2377), 
electronic connection between wheelchair controller and two or more power seating system motors (E2311) 
and harness for upgrade to expandable controller (E2313).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual routine exam and annual depression screening 
provided on June 8, 2022. 
 
You asked the Plan to pay for the evaluation and management services. You say that these services should be 
covered. You say that it is medically necessary to see a provider for an annual physical exam every 6 months. 
The Plan denied your request. The Plan says the benefits for these services have been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary].  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the evaluation and management services have not been met. The record shows that the Plan paid 
for an annual depression screening that you received on January 17, 2022, and an annual routine exam that you 
received on July 25, 2022. The record shows that the claim for July 25, 2022, was received before the claim for 
the date of service in this case. Therefore, we decided that the Plan does not have to pay for the annual routine 
exam and annual depression screening provided on June 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87651 billed for date of service June 25, 
2022. 
 
You asked the Plan to pay for procedure code 87651. You say that this service was medically necessary and is 
supported as billed. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87651 is infectious agent detection by nucleic acid (DNA 
or RNA); Streptococcus, group A, amplified probe technique. 
 
 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 87651. Our reviewer says that this service is 
not supported in the medical record. Our reviewer found the lab results do not show that Group A Strep was 
tested for; there are no negative or positive findings for this test. There is no evidence that the Group A strep 
test was performed. 
 
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 code 87651 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87651 billed for date of service June 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Zimmer Biomet Primagen allograft (20930). 
 
You asked the Plan to pre-approve the Zimmer Biomet Primagen allograft. You say that the enrollee is 
rescheduled for new surgery on January 18, 2023, with anticipation of the Plan approval. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the Zimmer Biomet Primagen Allograft in the 
setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Zimmer Biomet Primagen allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Zimmer Biomet Primagen allograft (20930).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for topical application of fluoride varnish (D1206), full mouth 
debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355), and 
house/extended care facility call (D9410) provided on August 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting the appeal to reverse the 
services that were declined, D1206, D9410 and D4355. The Plan denied your request. The Plan says these 
services are not covered under the benefit package.  
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 pay for topical 
application of fluoride varnish (D1206), full mouth debridement to enable a comprehensive oral evaluation and 
diagnosis on a subsequent visit (D4355), and house/extended care facility call (D9410) provided on August 30, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and re-cement or 
re-bond of a crown (D2920) provided on June 30, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you do not understand why these services were 
denied, as it was an emergency, and you could not have gone all weekend without getting it fixed. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the first intraoral periapical x-ray (D0220) and re-cement or re-bond of a crown (D2920) provided on 
June 30, 2022, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pulp cap - indirect (excluding final restoration) 
(D3120 x2). 
 
You asked the Plan to pre-approve the pulp cap - indirect (excluding final restoration) (D3120 x2). You say 
that you feel the procedure should be covered and the procedure is in progress. You also say that any help 
would be appreciated. The Plan denied your request. The Plan says this service is not covered under the benefit 
package. 
 
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 
pulp cap - indirect (excluding final restoration) (D3120 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic image obtained intra-orally or 
extra-orally (D0350 x4) provided on September 2, 2022. 
 
You asked the Plan to pay for the 2D oral/facial photographic image obtained intra-orally or extra-orally 
(D0350 x4). You say that you were given the in-network dentist numbers by the Plan. You are appealing the 
denial of dental procedure D0350. The Plan denied your request. The Plan says this service is not covered 
under the benefit package. 
 
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 pay for 2D 
oral/facial photographic image obtained intra-orally or extra-orally (D0350 x4) provided on September 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sinus augmentation (D7951) for tooth number 3. 
 
You asked the Plan to pre-approve sinus augmentation (D7951) for tooth number 3. You say that you wanted 
an implant procedure and not a partial bridge. The Plan denied your request. The Plan says the 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 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 sinus 
augmentation (D7951) for tooth number 3.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the drug testing coded 80307. We decided that the Plan does not have 
to pay for the mass spectrometry services coded 83789.  
 
You asked the Plan to pay for the drug testing coded 80307 and the mass spectrometry services coded 83789 
provided on July 26, 2022. You say that you disagree with the Plan's denial. The Plan says that the services 
rendered are not a covered benefit. 
 
We decided that the Plan has to pay for the drug testing coded 80307.  
 
The Plan follows Medicare rules. 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. 
 
Review of the file shows that code G0480 was paid by the Plan. However, the remittance documentation 
provided with the case file shows that code 80307 was not paid. The Plan did not provide explanation on why 
this code was not paid. The Plan did not substantiate their denial for this code. Therefore, we decided that the 
Plan has to pay for the drug testing coded 80307.  
 
We also decided that the Plan does not have to pay for the mass spectrometry services coded 83789. 
 
The Plan follows Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens used for drug testing shall not separately bill the validity testing. The mass spectrometry services are 
already included in codes 80307 and G0480. This means that code 83789 is not separately payable. Therefore, 
we decided that the Plan does not have to pay for the mass spectrometry services coded 83789. 
 
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 the use of Globus ViviGen allograft (20930). 
 
You asked the Plan to pre-approve Globus ViviGen allograft. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
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 Globus ViviGen allograft. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that Globus ViviGen allograft is experimental. More research is needed to demonstrate its 
safety and efficacy. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Globus ViviGen allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the use of Globus ViviGen allograft (20930).