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

 
We decided that the Plan does not have to pay for the emergency department visit for the evaluation and 
management of a patient (CPT code 99283) provided on April 20, 2022. 
 
You asked the Plan to pay for the service. You say that it is coded correctly along with the supporting 
documents to support CPT code 99283 for reconsideration of payment. The Plan denied your request. The Plan 
says the service is not covered by Medicare or the Health Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that are 
not covered or paid for by Medicare. K04.7 Periapical abscess without sinus is never covered by Medicare. 
Under the general exclusion of coverage, items and services in connection with the care, treatment, filling, 
removal, or replacement of teeth or structures directly supporting the teeth are not covered by Medicare. 
Diagnosis K04.7 is on this list that is never covered by Medicare. Therefore, we decided that the Plan does not have to pay for the emergency department visit for the evaluation and management of a patient (CPT code 
99283) provided on April 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 4, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contractual 
agreement for payment between the dialysis facility and the laboratory; therefore, these services should be paid 
separately. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 4, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Conforming bandage, non-elastic, knitted/woven, sterile 
(A6446) provided on August 29, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care supplies. You say that this enrollee has been treated for their 
wounds and billing separately for these supplies is appropriate. 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 Conforming bandage, non-elastic, knitted/woven, 
sterile (A6446) provided on August 29, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81599) provided on March 22, 2022. 
 
You asked the Plan to pay for a Nodify CDT test. You say that your laboratory provided services to the 
enrollee in good faith. In consideration for the services rendered, you are seeking adjudication of the submitted 
claim. You have done everything necessary to meet billing requirements and we are requesting that you re-
process the claim for payment. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Medicare rules confirm this test has not been approved by MoIDX as meeting Medicares 
reasonable and necessary requirement. Based on this information, we decided that Medicare rules for coverage 
of Nodify CDT test have not been met. Therefore, we decided that the Plan does not have to pay for genetic 
testing (81599) provided on March 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hyaluronan or derivative, gel-one, for intra-articular 
injection, per dose (CPT code J7326). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 the medication. Our physician reviewer 
found the documentation does not outline contraindications or reasons these medications were not considered. 
Without the support of the documentation, Gel-One is not approved as step therapy 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the hyaluronan or derivative, gel-one, for intra-articular injection, per dose (CPT code 
J7326).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable oxygen concentrator, rental (E1392). 
 
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 Medicare rules have not been 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 the DME. Our physician reviewer 
found a portable oxygen system is covered if the beneficiary is mobile within the home for Groups I and II, and 
the qualifying blood gas study (which includes pulse oximetry) was performed while at rest (awake) or during 
exercise. If coverage criteria are met, a portable oxygen system is usually separately payable in addition to the 
stationary system. In this case, the enrollee has portable tanks which are covered. 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve the portable 
oxygen concentrator, rental (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for five additional units of A9520 provided to the enrollee on 
August 3, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is no additional documentation or confirmation that indicates or support additional studies. 
 
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 A92520 is "Technetium tc-99m tilmanocept, diagnostic, 
up to 0.5 millicuries." 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records provided do 
not support the number of units billed by the provider, therefore this service cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for five additional units of A9520 provided to the enrollee on August 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 9, 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code 87632 is not covered. LCD A58577 says that this code is non-covered: 87632.  87486, 87581, 87541, 
87496, 87498 and 87532 are a part of a duplicate claim that is in process. 87503-XU x 2 MUE MAI 3 look at 
billing rule. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on 
February 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid, respiratory virus, 
12-25 targets (87633) provided on October 4, 2021. 
 
You asked the Plan to pay for the respiratory virus panel of 12-25 targets. You say that these services were 
medically necessary. The Plan denied your request. The Plan says this service is automatically denied as not 
medically necessary per Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that panels with more than five respiratory pathogens 
performed in the Part B outpatient setting are considered not medically reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the respiratory virus panel of 12-25 targets have not been met. Specifically, the service at issue 
includes more than five respiratory pathogens and was performed in a Part B setting. Therefore, we decided 
that the Plan does not have to pay for infectious agent detection by nucleic acid, respiratory virus, 12-25 targets 
(87633) provided on October 4, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that a skilled nursing facility would be the best option to 
help the enrollee stabilize. The Plan denied your request. The Plan says the services are not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 the home ventilator. Our physician 
reviewer found the enrollee may benefit from bilevel positive airway pressure (BiPAP) with average volume-
assured pressure support (AVAPS) during sleep.  This has not been tried and failed as an outpatient. Medicare 
does not cover a home ventilator when used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 19, 2022. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
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. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided on July 6, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you disagree with the denial and are requesting 
reconsideration of the payment on this claim. The Plan denied your request. The Plan says the claim for this 
molecular pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
 We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of genetic testing have 
not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81479) provided on 
July 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 11, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 11, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the emergency department visit coded 99285 provided on November 8, 
2021. 
 
You asked the Plan to pay for the emergency department visit. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says that the provider did not bill as required by the Medicare coding 
regulations. 
 
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 the Plan states that the provider did not bill as 
required by the Medicare coding regulations. The Plan also states that they would have overturned the decision 
at the Plan level if they had processed it within the required timeframe. We send a request for information 
asking for clarification if the claim had been processed/paid. No response was provided by the Plan. 
The Plan did not give any other reasoning as to why this claim was denied. No Medicare rules were referred to 
for reasoning of denial. Without reasoning as to why this claim was denied, the Plan did not substantiate their 
denial. Therefore, we decided that the Plan has to pay for the emergency department visit coded 99285 
provided on November 8, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound, breast, unilateral, real time with image 
documentation, including axilla when performed; complete (76641) provided on September 22, 2022. 
 
You asked the Plan to pay for the ultrasound. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is 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 ultrasound have not been met. CPT code 76641 26 RT and 
76641 26 LT was not billed in accordance with Medicare National Correct Coding Initiative Policy Medically 
Unlikely Edits (MUE). This is not a medical necessity denial. CPT code 76641 26 RT and 76641 26 LT is not 
billed in accordance with Medicare National Correct Coding Initiative Policy. Medically Unlikely Edits 
(MUE). This is not a medical necessity denial. CPT code 76641 26 RT and 76641 26 LT has an MUE value of 
1, but billed 2 units. Therefore, we decided that the Plan does not have to pay for ultrasound, breast, unilateral, 
real time with image documentation, including axilla when performed; complete (76641) provided on 
September 22, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90834) provided on May 
12, 2022 to May 19, 2022. 
 
You asked the Plan to pay for the outpatient mental health services. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the provider is not eligible for separate payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not eligible for Medicare 
payment. Therefore, we decided that the Plan does not have to pay for outpatient mental health services 
(90834) provided on May 12, 2022 to May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit for a new patient (99205) provided on May 
12, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is 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. 
 
Review of the file shows that the enrollee had an outpatient visit (99205) on March 4, 2021, with a provider 
under the same taxonomy and same specialty as the provider that performed the services on May 12, 2022. The 
services performed on March 4, 2021, which was processed and paid by the Plan to the physician. The same 
specialty physician is defined as a physician and/or other qualified health care. Professional of the same group 
and same specialty reporting the same taxonomy. Therefore, we decided that the Plan does not have to pay for 
the office visit for a new patient (99205) provided on May 12, 2022.