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

 
We decided that the Plan does not have to pay for the genetic testing provided on November 2, 2021 billed with 
codes 81206, 81210, 81235, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 81301, 81191, 81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that this letter and the attached documents 
support the medical necessity of the tests requested. The Plan denied your request. The Plan says the testing is 
not medically necessary and does not meet Medicare rules as the testing performed was not FDA approved. 
 
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 
November 2, 2021 billed with codes 81206, 81210, 81235, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 
81301, 81191, 81309.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service May 3, 2022. 
 
You asked the Plan to pay for procedure code 99140. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99140 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 99140 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service May 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an artificial left arm with fingers (L6955, L6611, 
L6629, L6890). 
 
You asked the Plan to pre-approve an artificial left arm with fingers. You say that you do not agree with the 
denial. The Plan denied your request. The Plan says this request cannot be approved at this time. There is not 
enough scientific evidence to show that the requested device is safe or helpful to treat your condition. 
 
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 an artificial left arm with fingers. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found an artificial left arm with fingers is not medically necessary per Social 
Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), as Medicare does not pay for any items or 
services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve 
the functioning of a malformed body member. There is insufficient evidence in the literature of the 
effectiveness of the requested device. 
 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 artificial left arm with fingers have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an artificial left arm with fingers (L6955, L6611, L6629, L6890).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services provided on June 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for pathology services. You say that an in-network provider ordered a blood biopsy 
and the pathology services in order to assist determining the optimal treatment options for the member. The 
Plan denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also 
says the services were not approved in advance. 
 
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 pathology services provided on June 23, 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 lab services provided on May 16, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was 
billed with the incorrect date of service. 
 
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 payment for CPT code 81455 is not supported in the medical record. Specifically, the claim must 
be billed with the date the specimen was collected. The records show that the specimen was collected on April 
15, 2022. As such, the claim was billed with the incorrect date of service. 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 the lab services provided on May 16, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from February 12, 2022, 
to March 13, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid NOA for the dates of service at issue. 
 
The Plan must follow Medicare rules. The rules say that HHAs must send a Notice of Admission (NOA) to 
Medicare by mail, electronic data interchange (EDI), or direct data entry (DDE). 
 
We looked at the file and Medicare rules. The file shows that there is no valid NOA for the billed dates of 
service. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from 
February 12, 2022, to March 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with an electronic knee, advanced foot 
feature, and other parts (L5828, L5845, L5848, L5856, L5981). 
 
You asked the Plan to pre-approve prosthetics. You say that the enrollee is currently in a microprocessor knee 
and K3 foot, therefore this is a like-to-like request. He has not had a decrease in functional capability, and it is 
reasonable observation that he will continue to do so, corroborated by his physician. The Plan denied your 
request. The Plan says the advanced foot is not covered due to your current functional level. 
 
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 prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a level 3 ambulator has the ability or potential for ambulation with variable cadence. Typical of 
the community ambulator who has the ability to traverse most environmental barriers and may have vocational, 
therapeutic or exercise activity that demands prosthetic utilization beyond simple locomotion. In this case, the 
documentation indicates that the enrollee uses assistive devices and a power wheelchair for locomotion.  This is 
not consistent with a need for an advanced K3 foot and a microprocessor 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 prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a prosthetic leg with an electronic knee, advanced foot feature, and other parts (L5828, 
L5845, L5848, L5856, L5981).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on June 9, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets.  
 
We looked at the file and Medicare rules. The panel in question was billed with multiple codes, not one unit of 
one code as required by Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
testing provided on June 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on June 22, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that the member meets the requirements for the testing 
and has been determined by the Centers for Medicare and Medicaid Services (CMS) to be reasonable and 
necessary for the management of the member's advanced cancer. The Plan denied your request. The Plan says 
the services were not authorized because the provider is a non-network provider who does not work with the 
Plan. The Plan also says the member was referred by a provider who also does not work with the Plan. 
 
  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 genetic testing provided on June 22, 2021, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail debridement provided on April 12, 2022, billed with 
code 11721-59. 
 
You asked the Plan to pay for the nail debridement. You say that you feel that modifier -59 is correct for use 
with code 11721, and that it should be paid. The Plan denied your request. The Plan says the services at issue 
were billed with modifier -GY which means it is noncovered. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
nail debridement have not been met. Therefore, we decided that the Plan does not have to pay for the nail 
debridement provided on April 12, 2022, billed with code 11721-59.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mechanical traction therapy services (97012 x 7) 
provided from May 21, 2022, through June 13, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered under your 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. However, the Plan provides supplemental coverage 
for spine x-rays and chiropractic radiology services.  
 
The records show that the services at issue do not meet criteria for coverage by the Plan or by Medicare. 
Therefore, we decided that the Plan does not have to pay for the mechanical traction therapy services  
(97012 x 7) provided from May 21, 2022, through June 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88305) provided on January 20, 2022. 
 
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 the code billed is 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 code 88305 is not supported in the medical record. Specifically, this code has a professional 
component / technical component indicator of 1. The claim was billed with an outpatient hospital place of 
service. Payment for this service is made to the facility. 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 (88305) provided on January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90970 billed for date of service January 21, 
2022 to January 30, 2022. 
 
You asked the Plan to pay for procedure code 90970. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that 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 90970 is 1. The MAI value for this code is 2. You billed 11 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 90970 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 90970 billed for date of service January 21, 2022 to January 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service March 26, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that the services were medically necessary. The 
Plan denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service March 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87799 billed for date of service August 26, 
2021 to September 20, 2021. 
 
You asked the Plan to pay for procedure code 87799. The Plan denied your request. The Plan says payment for 
code 87799 is bundled into payment for code 87798. 
 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 87799 
is a column II code to column I code 87798. 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 87799 billed for date of service August 26, 2021 
to September 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (81540) provided on April 14, 2021. 
 
You asked the Plan to pay for laboratory 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 not billed in 
accordance with Medicare rules, as the required DEX Z-Code is missing from this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that to report a Molecular Diagnostic Test service in the state where this test was provided, the 
appropriate CPT code must be selected with one unit of service along with the appropriate DEX Z-Code 
identifier. 
 
We looked at the file and Medicare rules. This claim was not billed with the necessary DEX Z-Code. Based on 
this information, we decided that Medicare rules for coverage of laboratory testing have not been met. 
Therefore, we decided that the Plan does not have to pay for laboratory testing (81540) provided on April 14, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy rendered from February 26, 2022, 
to March 25, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services 
were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion 
therapy rendered from February 26, 2022, to March 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 22, 2021, billed 
with codes 81286, 81407, 81408, and 81439. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says Medicare guidelines for coverage have not been met. 
 
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 
September 22, 2021, billed with codes 81286, 81407, 81408, and 81439.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan has to pay for the services (61783) provided on December 16, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed code is 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 61783 is "Stereotactic computer-assisted (navigational) procedure; spinal (List separately in addition to 
code for primary procedure)". 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 61783 is 
supported by the records provided. Our reviewer found that procedure code 61783 is documented and payable 
in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
the services (61783) provided on December 16, 2021.  
 
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 laboratory testing (0089U) provided on December 14, 2021. 
 You asked the Plan to pay for laboratory 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 not billed in 
accordance with Medicare rules, as the required DEX Z-Code is missing from this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that to report a Pigmented Lesion Assay service in the state where this test was provided, the 
appropriate CPT code must be selected with one unit of service along with the appropriate DEX Z-Code 
identifier. 
 
We looked at the file and Medicare rules. This claim was not billed with the necessary DEX Z-Code. Based on 
this information, we decided that Medicare rules for coverage of laboratory testing have not been met. 
Therefore, we decided that the Plan does not have to pay for laboratory testing (0089U) provided on December 
14, 2021.