Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair component or accessory, not otherwise 
specified, push handles (K0108) wheelchair component or accessory, not otherwise specified, gel cover hanger frames (K0108) wheelchair component or accessory, not otherwise specified, gel and foam foot protector 
(K0108) wheelchair component or accessory, not otherwise specified, transit system (K0108). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that please reconsider the 
documentation provided for the wheelchair and accessories that are medically necessary to meet the enrollee's 
current needs. The Plan denied your request. The Plan says these items are convenience items and items that do 
not serve a primary medical purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to 
pre-approve wheelchair component or accessory, not otherwise specified, push handles (K0108) wheelchair 
component or accessory, not otherwise specified, gel cover hanger frames (K0108) wheelchair component or 
accessory, not otherwise specified, gel and foam foot protector (K0108) wheelchair component or accessory, 
not otherwise specified, transit system (K0108).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for respiratory pathogen testing (87496, 87498, 87502 and 87532) 
provided on June 28, 2022. 
 
You asked the Plan to pay for respiratory pathogen testing. You say that these services were necessary and 
should be paid. The Plan denied your request. The Plan says that they have agreed to pay for some of the codes 
at issue; however, codes 87496, 87498, 87502 and 87532 were not billed in accordance with Medicare 
guidelines. A Local Coverage Determination (LCD L38916) and Local Coverage Article (LCA A58575) state 
that a respiratory pathogen panel test is a single service with a single unit of service. A respiratory pathogen 
panel test must not be unbundled and billed as individual 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. Specifically, the Local Coverage Determination and Local Coverage Article 
cited by the Plan do not apply to the state where these services were performed. There is no similar LCD/LCA 
for the relevant state in this case, and the Plan has provided no other reason for denial. Therefore, we decided 
that the Plan has to pay for respiratory pathogen testing (87496, 87498, 87502 and 87532) provided on June 28, 
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 drug testing services (22+ drug classes) provided to the 
enrollee on June 23, 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 under Medicare rules, the requested number of definitive urine drug classes are 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provider records note no concern for drug abuse or misuse. The urine drug screen and pill counts 
were appropriate. The urine drug testing was not tailored to the enrollee's addictions, medications, or 
abuse/misuse concerns. Therefore, the documentation does not support that the provided, broad-sweeping, 
confirmatory urine drug testing was medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services (22+ drug classes) provided to the enrollee on June 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Q-Grip neoprene coated, aluminum side guard, and 
custom mounting of aluminum side guard. 
 
You asked the Plan to pre-approve Q-Grip neoprene coated, aluminum side guard, and custom mounting of 
aluminum side guard. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan 
says the requested items are not a covered benefit. 
 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 Q-Grip neoprene coated, aluminum side guard, and custom 
mounting of aluminum side guard.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration-resorbable barrier, per site 
(D4266 x 2), bone replacement graft for ridge preservation-per site (D7953 x 2), and the therapeutic parenteral 
drugs, two or more administrations, of different medications (D9612) provided on June 20, 2022.  
You asked the Plan to pay for these items/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 items/services are not a covered 
benefit. 
 
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 items/services provided are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
guided tissue regeneration-resorbable barrier, per site (D4266 x 2), bone replacement graft for ridge 
preservation-per site (D7953 x 2), and the therapeutic parenteral drugs, two or more administrations, of 
different medications (D9612) provided on June 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair component or accessory, not otherwise 
specified, tie down kit (K0108). 
 
You asked the Plan to pre-approve the tie down kit. You say that please review the attached medical 
documentation to support the need of the custom medical equipment being requested for the enrollee. The Plan 
denied your request. The Plan says a tie down kit is not primarily medical in nature and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the tie down kit have not been met. Therefore, we decided that the Plan does not have to pre-
approve the wheelchair component or accessory, not otherwise specified, tie down kit (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 4, 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 procedure code 87481 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 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. 
 
We find that CPT code 87481 is not supported in the medical record. Specifically, there is no documentation of 
infectious agent detection by nucleic acid, candida species, amplified probe technique. 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 laboratory services rendered on May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921x2) and the drugs or 
medicaments dispensed in the office for home use (D9603x2) provided on June 8, 2022. 
 
You asked the Plan to pay for the gingival irrigation (D4921x2) and the drugs or medicaments dispensed in the 
office for home use (D9630x2). You say that services from this provider have been covered in the past. The 
Plan denied your request. The Plan says the services are not covered 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.  
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 
gingival irrigation (D4921x2) and the drugs or medicaments dispensed in the office for home use (D9603x2) 
provided on June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026) provided on June 14, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 The Plan must follow Medicare rules. The rules say that effective for services performed on and after  
October 24, 2006, the Centers for Medicare & Medicaid Services has determined that there is sufficient 
evidence to conclude the use of infrared therapy devices and any related accessories is not reasonable and 
necessary under section 1862(a)(1)(A) of the Social Security Act (the Act).  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the infrared therapy service provided have not been met. Specifically, Medicare rules say that there is sufficient 
evidence to conclude that the use of infrared therapy devices and any related accessories is not reasonable and 
necessary. Therefore, we decided that the Plan does not have to pay for the infrared therapy (97026) provided 
on June 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the criteria for coverage have not been met. 
Specifically, the enrollee is confirmed to not be asymptomatic as required for Medicare coverage of the 
requested imaging service. Therefore, we decided that the Plan does not have to pre-approve a low dose 
computed tomography (LDCT) scan for lung cancer screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99051 billed for date of service July 18, 
2022. 
 
You asked the Plan to pay for procedure code 99051. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says procedure code 99051 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 99051 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99051 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99051 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99051 billed for date of service July 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 14, 2022, billed with 
codes 81292. 
 
You asked the Plan to pay for the genetic testing 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 14, 2022, billed with codes 81292.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiographic image (D0330) and the risk assessment and 
documentation (D0603) provided on May 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental services were an emergency, and the 
provider is an in-network provider. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. Also, the denial of payment for the risk assessment and 
documentation is correct, because it is not covered by 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, certain limitations apply. The record 
shows your benefit for the radiographic image was exhausted on the date of service of May 28, 2022. The risk 
assessment and documentation are not covered under the Plans dental benefit. Therefore, we decided that the 
Plan does not have to pay for a radiographic image (D0330) and the risk assessment and documentation 
(D0603) provided on May 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upright walker. 
 
You asked the Plan to pre-approve an upright walker. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a standard walker (E0130, E0135, E0141, E0143) and 
related accessories are covered if certain criteria 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 an upright walker. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found Medicare covers a standard walker. 
Criteria for a standard walker are met but the request is for an upright walker. 
 
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 upright walker have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an upright walker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller components represented by code 
E2311. 
 
You asked the Plan to pre-approve code E2311. You say that the records provided support the need for the item 
which remains in dispute. The Plan denied your request. The Plan says the enrollee's upper extremity function 
is adequate to control the power options using their own switch. The Plan says that there is no need to control 
the power option through the joystick. 
 
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 code E2311. Our reviewer says that 
expandable controller components are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require a ventilator, or non-proportional input devices. The enrollee does not require a separate display, other electronic devices, or an attendant control. The enrollee has 
power options on the wheelchair but does not need to control the power options through a joystick. The 
enrollee's upper extremity strength supports that the enrollee can control any power options through their own 
switches.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code E2311 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve expandable controller components represented by code E2311.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement graft for ridge preservation (D7953) 
provided on August 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you made an appointment after checking the 
plan website, where you found 10 in-network providers. You were surprised to receive denial notices for your 
services. 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. Bone replacement graft for 
ridge preservation (D7953) is not covered under the Plans dental benefits under any circumstance. 
 
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 bone replacement graft for ridge 
preservation (D7953) is not covered under this benefit when received from an in-network or out-of-network 
provider. Therefore, we decided that the Plan does not have to pay for bone replacement graft for ridge 
preservation (D7953) provided on August 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0230) provided on 
August 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the dentist was an in-network 
provider and would like the Plan to pay for the dental services. The Plan denied your request. The Plan says 
your benefit for the requested item or service 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 requested item or service was exhausted on the date of service of August 16, 2022. 
Therefore, we decided that the Plan does not have to pay for the intraoral radiographic images (D0230) 
provided on August 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood smear interpretation (85060) billed for date of service 
July 20, 2022. 
 
You asked the Plan to pay for blood smear interpretation. You say that this service was rendered in an 
appropriate place of service. The Plan denied your request. The Plan says this service is not payable when it is 
furnished to hospital outpatients or non-hospital patients. The Place of Service (POS) code used on this claim is 
for outpatient hospital; therefore, this service cannot be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that no payment is recognized for 
code 85060 furnished to hospital outpatients or non-hospital patients. We find that CPT code 85060 is not supported in the medical record. Specifically, the record shows that this 
service was furnished to a hospital outpatient. No payment for code 85060 is recognized in this case. Based on 
this information, we decided that Medicare rules for coverage of blood smear interpretation have not been met. 
Therefore, we decided that the Plan does not have to pay for blood smear interpretation (85060) billed for date 
of service July 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 11, 2022, to June 9, 
2022. 
 
You asked the Plan to pay for home health services. You say that an NOA was submitted with the final claim. 
The Plan denied your request. The Plan says an NOA was not received. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is May 11, 2022. The NOA was not received by the Plan until July 7, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
May 11, 2022, to June 9, 2022.