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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 25, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed and 
approved for payment. 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 March 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cold therapy pump (CPT code E0218). 
 
You asked the Plan to pre-approve a cold therapy pump. You say that you will be going under surgery on 
August 23, 2022, and you will need the automatic ice machine for after care surgery. The Plan denied your 
request. The Plan says the requested equipment is non covered as it is not medically reasonable or 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 a cold therapy pump have not been met. The rules say a fluid 
circulating cold pad with pump (E0218) will be denied as not reasonable and necessary. Therefore, we decided 
that the Plan does not have to pre-approve a cold therapy pump (CPT code E0218).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services (CPT code(s): 23615, 24515, 27536, 
27814, 27829) provided on April 21, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that The Medicare Fee Schedule Data Base (MFSDB) 
provides the postoperative periods that apply to each surgical procedure.  If there is an indicator of 000, 
postoperative visits beyond the day of the procedure are not included in the payment amount for the surgery.  
 
We looked at the file and Medicare rules. Review of the file shows that the treatment of thigh fracture (CPT 
code 27506) performed on April 19, 2021, was paid by the Plan. Further review shows that the global surgical 
package for all of the services is 90 days. Therefore, the services are included in the payment of 27506 and 
each code requested for payment is not separately reimbursable. Therefore, we decided that the Plan does not 
have to pay for the surgical services (CPT code(s): 23615, 24515, 27536, 27814, 27829) provided on April 21, 
2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on January 3, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this testing service is eligible for coverage per 
Medicare rules. The Plan denied your request. The Plan says that there is a Local Coverage Determination 
(LCD) that indicates that any panel that tests for the FANCC gene is noncovered. They argue that since this 
panel includes that specific gene, the denial is correct. 
 
We reviewed the LCD cited by the Plan but find that it is not applicable to an FDA-approved test, as these are 
covered via the NCD cited in the Medicare rules section. An LCD cannot limit coverage allowed by an NCD, 
per the Medicare hierarchy of authority. As such, we disregarded the LCD cited by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to a patient with a solid tumor. The FDA 
approval notice indicates that this panel is approved for solid tumors. No other valid denial rationale was 
presented by the Plan. Based on this information, we decided that Medicare rules for coverage of F1CDx 
testing have been met. Therefore, we decided that the Plan has to pay for the FoundationOne CDx (F1CDx) 
testing provided on January 3, 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 genetic testing provided on July 30, 2021 billed with 
codes 81301 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 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 
July 30, 2021 billed with codes 81301 and 81479.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is no documentation submitted that the 
enrollee has an acute medical issue that requires an initial acute inpatient level of care admission. 
 
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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. There is no 
documentation submitted that the enrollee has an acute medical issue that requires an initial acute inpatient 
level of care admission. Also, she does not require at least 2 overnight stays under inpatient level of care. The 
record does not show that at the time of inpatient admission that the patient's necessary hospital care would 
span two midnights Our physician reviewer found that the enrollee's condition does not meet criteria for 
coverage of inpatient hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on April 12, 2022. 
 
You asked the Plan to pay for the panoramic x-ray. You say that you were under the impression that the 
provider was in network. The Plan denied your request. The Plan says your benefit for the panoramic x-ray has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the panoramic x-ray was exhausted on date of service November 1, 2021. Therefore, we 
decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on April 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically reasonable and necessary for 
your condition. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you are currently medically stable and do not need a physical medicine and 
rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute nursing needs identified or 
documented. At the current functional level, you will not make a significant functional recovery in an IRF in a 
predicted period of 7-10 days. You do not need three hours a day therapy services five days a week. The lack of 
medical complexity and lack of nursing needs do not support an acute hospital inpatient rehab admission with 
an interdisciplinary approach to rehabilitation care. While you would benefit from certain therapy services, 
your rehab needs can be safely provided in an alternate and low intensity setting such as in a skilled nursing 
facility or in long-term care with intermittent services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of plaque, calculus and stains from the tooth 
structures and implants (D1110) and a periodic oral evaluation (D0120) provided on January 20, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the removal of plaque, calculus and stains from the tooth structures and implants 
and a periodic oral evaluation. You say that you do not feel that you should have to pay this as you submitted 
an out-of-network claim form. The Plan denied your request. The Plan says these services are only covered 
when received by a participating provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the removal of plaque, calculus and stains from 
the tooth structures and implants (D1110) and a periodic oral evaluation (D0120) provided on January 20, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service January 20, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service January 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not agree with the denial reason. 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 dental services provided on March 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on December 27, 2021.

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 the services were reported without a required anatomical modifier.

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 the denied codes is:

CPT 64445:

Injection(s), anesthetic agent(s) and/or steroid; sciatic nerve

CPT 64447:

Injection(s), anesthetic agent(s) and/or steroid; femoral nerve

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 an anesthetic injection is supported in documentation; however, both procedure codes requires an anatomical modifier. The services were billed incorrectly.

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 anesthesia services provided to the enrollee on December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental evaluation and dental extractions. 
 
You asked the Plan to pre-approve the dental services. You say that you are in a lot of pain. The Plan denied 
your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve dental 
evaluation and dental extractions.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 26, 2021 billed with 
codes 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301 and 81311. 
 
You asked the Plan to pay for the genetic testing billed. 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 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 
October 26, 2021 billed with codes 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301 and 81311.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs to the rear shroud and the controller harness. 
 
You asked the Plan to pre-approve the rear shroud and the controller harness repairs. You say that this 
equipment is necessary for the enrollee's condition. The Plan denied your request. The Plan says the repairs for 
these items are not reasonable and necessary. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The rear shroud 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. It is not 
necessary to repair an accessory that does not serve a medical purpose. In addition, the controller harness is 
considered part of the drive control interface repair and no separate payment will be made as it is included in its 
repair services. 
 
 Therefore, we decided that the Plan does not have to pre-approve repairs to the rear shroud and the controller 
harness.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services on December 16, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. 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 dental services on December 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment purchased from January 31, 
2022, through February 9, 2022, by a provider not contracted with Medicare. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like to be reimbursed for 
these services. The Plan denied your request. The Plan says this provider does not participate with Medicare 
and cannot accept 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 enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the durable medical equipment 
purchased from January 31, 2022, through February 9, 2022, by a provider not contracted with Medicare.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 87801, 87481, 87640m 87653, and 87798 
billed for date of service October 18, 2021. 
 
You asked the Plan to pay for procedure code 87801, 87481, 87640m 87653, and 87798. You say that you 
disagree with the denial. The Plan denied your request. The Plan says payment for code 87801, 87481, 87640m 
87653, and 87798 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 87801, 
87481, 87640m 87653, and 87798 are column II codes to column I code 87801. 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 87801, 87481, 
87640m 87653, and 87798 billed for date of service October 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81161, 81404, 81407, and 
81408 provided on July 6, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
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 laboratory services at issue in this appeal were 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 the 
laboratory services coded 81161, 81404, 81407, and 81408 provided on July 6, 2021.