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

 
We decided that the Plan has to pay for the laboratory services (87150, 87798, and 87481) provided on 
November 7, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87798, and 87481. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says that a test panel is a single 
test with multiple components and is characterized by a single unit of service. A panel cannot be unbundled and 
billed as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. This panel was unbundled and billed as separate components. 
 
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. In this case, we find that the Plan has not provided enough evidence to support 
the denial of payment for procedure codes 87150, 87798, and 87481 based on Medicare criteria. The Plan has 
provided no Medicare citations or regulations used by the Plan to deny payment for the reasons stated. 
Therefore, we decided that the Plan has to pay for the laboratory services (87150, 87798, and 87481) provided 
on November 7, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Aptima swab vaginitis panel coded as 81513 87481 and 
87661, provided May 10, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that say the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the request does not meet the 
Medicare rules and is not medically necessary. 
 
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 service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records didn't describe this enrollee as at high risk for sexually transmitted 
infections to justify a broad panel to include these organisms. Therefore, this request for such testing will be 
considered 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. Therefore, we decided that the Plan 
does not have to pay for the Aptima swab vaginitis panel coded as 81513 87481 and 87661, provided May 10, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81401, 81226, 81328, and 81291 billed for 
date of service May 31, 2022. 
 
You asked the Plan to pay for procedure codes 81401, 81226, 81328, and 81291. You say that you disagree 
with the denial. The Plan denied your request. The Plan says the services are not covered. 
 
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 81401 
is a column II code to column I code 87637. 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.  
 
Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid 
when the MAI value is 2.  
 
In this case, the MUE for CPT code 81328 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. 
 
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. The file shows that codes 81226 and 81291 were 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 these services have not been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 81401, 81226, 81328, and 81291 
billed for date of service May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure codes 87150, 87798, 87640, and 87641 billed for 
date of service December 15, 2021. 
 
You asked the Plan to pay for procedure codes 87150, 87798, 87640, and 87641. You say that you disagree 
with the denial. The Plan denied your request. The Plan says payment for codes 87150, 87798, 87640, and 
87641 is bundled into payment for code 87500. 
 
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 
87150, 87798, 87640, and 87641 are column II codes to column I code 87500. This claim has not been billed 
with an appropriate modifier to bypass the edit. The -XU modifier is not supported as a separate and distinct 
procedural service. 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, 87640, and 87641 billed for date 
of service December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0453 billed for date of service May 12, 
2022. 
 
You asked the Plan to pay for procedure code G0453. You say that you believe that the Plan did not pay you 
correctly for these services. The Plan denied your request. The Plan says payment for code G0453 is bundled 
into payment for code 51785. 
 
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 G0453 
is a column II code to column I code 51785. 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 G0453 billed for date of service May 12, 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), an expandable controller (E2377), 
wheelchair accessory, power seat elevation system (E2300) and wheelchair component or accessory, not 
otherwise specified (K0108). 
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and two or more 
power seating system motors, a harness, an expandable controller, power seat elevation system and wheelchair 
component or accessory. You say that these upgrades are necessary. The Plan denied your request. The Plan 
says there is not a medical need to control these power options through the joystick. 
 
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 electronic connection between 
wheelchair controller and two or more power seating system motors, a harness, an expandable controller, 
power seat elevation system and wheelchair component or accessory. Our reviewer says that an electronic 
connection between wheelchair controller and two or more power seating system motors, a harness and an 
expandable controller are not medically necessary. Our physician reviewer found that the enrollee has adequate 
strength to manage standard switches on a power wheelchair and does not require a single point of control for 
the power drives. 
 
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 electronic connection between wheelchair controller and two or more power 
seating system motors, a harness, and an expandable controller have not been met. The power seat elevation 
system and wheelchair component or accessory and not covered under Medicare. 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), an expandable controller (E2377), wheelchair 
accessory, power seat elevation system (E2300) and wheelchair component or accessory, not otherwise 
specified (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a scooter car rack (A9270). 
 
You asked the Plan to pre-approve a scooter car rack. You say that you do not agree with the Plan's denial. The 
Plan denied your request. The Plan says the requested item is available to the public and is not primarily 
medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a scooter car rack (A9270).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Kyphoplasty and Vertebroplasty (22514 and 22515). 
 
You asked the Plan to pre-approve a Kyphoplasty and Vertebroplasty. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary when the criteria listed in the LCD 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 a Kyphoplasty and Vertebroplasty. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found detailed 
documentation is not evident regarding diagnostic imaging corroborating an acute or subacute vertebral 
fracture. Additionally, a trial and failure of recent, reasonable, comprehensive less invasive conservative care 
measures including physical therapy is not clearly documented. 
 
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 Kyphoplasty and Vertebroplasty have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Kyphoplasty and Vertebroplasty (22514 and 22515).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot plate/bracket assembly and a lateral positioning 
wedge for a wheelchair. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the items at issue are already included in the approved services. 
 
The Plan must follow Medicare rules. The rules say that wheelchair seat and back cushion codes are all-
inclusive and a foot plate bracket assay is included in codes K0040, K0041, and K0042.  
 
We looked at the file and Medicare rules. The requested lateral positioning wedge and foot plate bracket assay 
are already included in the approved power wheelchair accessories. Therefore, we decided that the Plan does 
not have to pre-approve foot plate/bracket assembly and a lateral positioning wedge for a wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for glycosylated (A1C) hemoglobin testing (83036) provided on 
July 6, 2022. 
 
You asked the Plan to pay for A1C hemoglobin testing. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this test was provided as a 
screening in this case and was not provided for a covered indication. 
 
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, A1C hemoglobin 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 glycosylated (A1C) hemoglobin testing (83036) provided on July 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair battery. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services cannot be approved as requested. 
 
The Plan must follow Medicare rules. The rules say that a sealed battery is described by codes E2359, E2361, 
E2363, E2365, E2371, E2397, and K0733. 
 
We looked at the file and Medicare rules. The file shows that the battery was requested under code K0108. This 
code cannot be approved, as it is not the appropriate code for the requested services. Therefore, we decided that 
the Plan does not have to pre-approve a power wheelchair battery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve an inpatient hospital admission. You say that the records provided support 
the need for an inpatient hospital admission. The Plan denied your request. The Plan says the planned 
procedure is not on the Inpatient Only List. The Plan says that there is no documentation provided to support 
the expectation that the enrollee will require greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   

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 inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for coverage of an inpatient hospital 
admission have met in this case. Our physician reviewer found the record does not show that at the time of the 
request for an inpatient admission, the requesting physician reasonable expected that the enrollee's necessary 
hospital care would span two midnights. Detailed documentation is not evident regarding a significant past 
and/or current medical history that would place this enrollee at increased risk for peri-surgical complications 
requiring an inpatient stay. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. 
 
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 inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedure codes L5828, L5845, L5848, L5856, L5986, 
and L5987. 
 
You asked the Plan to pre-approve procedure codes L5828, L5845, L5848, L5856, L5986, and L5987. You say 
that the enrollee clearly meets all Medicare requirements to utilize a Microprocessor knee and L5987 foot. You 
also say that the ordering physician documented that the enrollee needs these to meet their functional level and 
to help with energy consumption. The Plan denied your request. The Plan says the notes do not show why the 
parts of your prosthesis are needed. The Plan says that there are other knees and feet that can meet your needs.  
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of knee. 
 
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 procedure codes L5828, L5845, L5848, 
L5856, L5986, and L5987. Our reviewer says that the requested prosthetic components are not medically 
necessary. Our physician reviewer found that neither the prosthetist nor the physician have provided 
documentation support the choice of a microprocessor knee instead of a mechanical knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes L5828, L5845, L5848, L5856, L5986, and L5987 have not 
been met. Therefore, we decided that the Plan does not have to pre-approve procedure codes L5828, L5845, 
L5848, L5856, L5986, and L5987.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
(D0610) provided July 20, 2022. 
 
You asked the Plan to pay for the dental procedure. You say that it was medically necessary to place implants 
#23 and #26 to keep the dentures in place. Please take this matter into reconsideration. The Plan denied your 
request. The Plan says this service is not covered under the Plan. 
 
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 the 
surgical placement of implant body: endosteal implant (D0610) provided July 20, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 and 99233 
provided from September 10, 2021, to September 14, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
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 subsequent hospital care services coded 99232 
and 99233 provided from September 10, 2021, to September 14, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the validity testing (83789) provided on August 9, 2022. 
 
You asked the Plan to pay for the validity testing. You say that this testing should be covered. The Plan denied 
your request. The Plan says validity testing is not separately reimbursed. 
 
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 validity 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 validity testing (83789) provided on August 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 20, 2022, billed with 
codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81238, 81291, 81306, 81335, 81355, 81407 and 
81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported as billed. 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 20, 2022, billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81238, 81291, 81306, 
81335, 81355, 81407 and 81479.