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

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA) 
(85707) provided February 10, 2021. 
 You asked the Plan to pay for the laboratory service. You say that the enrollee was seen by the doctor out of 
medical necessity. The primary diagnosis billed is covered by Medicare. The Plan denied your request. The 
Plan says procedure code 87507 has not met the associated diagnosis code. 
 
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 87507 is Infectious agent detection by nucleic acid (DNA 
or RNA);  gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, 
Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, 
multiple types or subtypes, 12-25 targets). 
 
We find that CPT code 87507 is not supported in the medical record. Specifically, per LCA A56706, for 
immunosuppressed patients, to bill for 87507 or 0097U, an ICD-10 diagnosis code from Group 2 must be on 
the claim in addition to an ICD-10 diagnosis code from Group 1. The claim was not billed correctly with 
diagnosis codes from both Group 2 and Group 1 as listed, that support medical necessity. Based on this 
information, we decided that Medicare rules for coverage of the laboratory service have not been met. 
Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid 
(DNA or RNA) (85707) provided February 10, 2021.
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 January 21, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you would like this claim reprocessed and 
approved for payment. 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 January 21, 2022.
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 May 2, 2022. 
 
You asked the Plan to pay for procedure code 99100. 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 May 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 8, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was 
submitted 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 0239U 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 July 
28, 2021. 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 August 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. 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 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 a home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found provided records document that the 
home ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) mode with 
auto-titration (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. As stated in 
the Local Coverage Determination (L33800): "Claims for ventilators used to provide continuous positive 
airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and necessary." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel, 51 or greater 
genes (81455) provided February 11, 2022 
 
You asked the Plan to pay for the laboratory service. You say that the FoundationOne HEME was ordered by 
the treating physician because the test results were needed to help determine the course of treatment for this 
enrollee. The Plan denied your request. The Plan says the services do not meet Medicare NCD/LCD criteria. 
 
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 81455 is targeted genomic sequence analysis panel, solid 
organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes 
(eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, 
KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), 
interrogation for sequence variants and copy number variants or rearrangements, if performed. 
 
We find that CPT code 81455 is not supported in the medical record. Specifically, the claim was billed with a 
date of service inconsistent with Medicare rules governing laboratory services. The specimen was collected on 
January 28, 2022, rather than the billed date of service February 11, 2022. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided 
that the Plan does not have to pay for the targeted genomic sequence analysis panel, 51 or greater genes 
(81455) provided February 11, 2022
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the presumptive drug testing services (80307) provided on July 20, 
2021. 
 
You asked the Plan to pay for procedure code 80307. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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 denied the presumptive drug testing as it has already been billed by another provider for the date of 
service at issue. The case file does not include a paid claim or any other documentation to show that the test 
with code 80307 was paid to another provider. The records in this case do support the billing of code 80307, 
and this code has not been paid to any provider for this date of service. The Plan has not made reasonable and 
diligent efforts to gather and forward to us information regarding their decision to deny your request. 
Therefore, we decided that the Plan has to pay for the presumptive drug testing services (80307) provided on 
July 20, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost share for an office visit on March 16, 2022. 
 
You asked the Plan to waive the cost share for an office visit. You say that you should not be responsible to pay 
for this. The Plan denied your request. The Plan says that the cost share was applied correctly. 
 
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. The Plan did not submit a copy of the 2022 Evidence of Coverage (EOC). This 
means that we cannot determine the cost you are being asked to pay is correct or justified by the Plan contract.  
Therefore, we decided that the Plan has to waive the cost share for an office visit on March 16, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a functional electrical stimulator, transcutaneous 
stimulation of nerve and/or muscle groups (E0770). 
 
You asked the Plan to pre-approve a functional electrical stimulator. You say that the requested device is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria. 
 
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 a functional electrical stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation in the records that the enrollee has participated 
in a functional therapy stimulator program with at least 32 sessions. There is also no documentation that the 
enrollee has muscle atrophy. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a functional electrical stimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a functional electrical stimulator, transcutaneous stimulation of nerve 
and/or muscle groups (E0770).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an incisional biopsy (D7286) provided on March 9, 2022, 
and periodontal scaling and root planing (D4341) provided on April 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the requested dental services are not covered. 
 
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 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for an incisional biopsy (D7286) 
provided on March 9, 2022, and periodontal scaling and root planing (D4341) provided on April 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 73706 and 74176 billed for date of service March 8, 
2022. 
 
You asked the Plan to pay for codes 73706 and 74176. You say that you do not believe these codes should be 
bundled. The Plan denied your request. The Plan says payment for codes 73706 and 74174 is bundled into 
payment for code 75635. 
 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 73706 
and 74174 is a column II code to column I code 75635 with a modifier indicator of 0. The column II code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for codes 73706 and 74176 billed for date of service March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 6, 2022, to April 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that the closest in-network provider is an hour away, 
round trip. 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 April 6, 2022, to April 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper extremity prosthesis test socket (L6680). 
 
You asked the Plan to pre-approve the upper extremity prosthesis test socket. You say that this feature is 
medically necessary. The Plan denied your request. The Plan says the requested feature does not meet coding 
requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of L-codes with specific amputation 
levels proximal to partial hand level would be considered incorrect coding. 
 
We looked at the file and Medicare rules. The enrollee was approved for a complete hand prosthesis. Separate 
components cannot be billed additionally to the complete prosthesis. The requested code is for a component 
that is for a wrist disarticulation or below elbow amputation. The enrollee does not have a wrist disarticulation 
or below elbow amputation. Based on this information, we decided that Medicare rules for coverage of the 
upper extremity prosthesis test socket have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an upper extremity prosthesis test socket (L6680).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic dental casts (D0470) provided on April 28, 
2022. 
 
You asked the Plan to pay for the diagnostic dental casts. You say that these services were medically 
appropriate, and it is in bad faith to deny this claim. The Plan denied your request. The Plan says this service is 
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 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 
diagnostic dental casts (D0470) provided on April 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires the intensity of an ARU to 
make a full recovery. The Plan denied your request. The Plan says this is not medically necessary; needs can be 
met at an alternate level of care. 
 
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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different level of care. 
 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274), intraoral imaging (D0220 and D0230), a 
panoramic radiographic image (D0330), and a periodic oral evaluation (D0120), provided by an out-of-network 
provider on November 24, 2021. 
 
You asked the Plan to pay for the dental services. You say that this dentist was recommended by your regular 
dentist. 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 bitewings (D0274), intraoral imaging (D0220 and D0230), a panoramic radiographic image (D0330), 
and a periodic oral evaluation (D0120), provided by an out-of-network provider on November 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220 and D0230), bitewings (D0270), 
and a limited oral evaluation (D0140), provided by a participating provider on March 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for this. 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 D0220, D0230, D0270, and one D0140 was exhausted on date of service January 19, 
2022, and the second oral evaluation was exhausted on February 28, 2022. Therefore, we decided that the Plan 
does not have to pay for intraoral imaging (D0220 and D0230), bitewings (D0270), and a limited oral 
evaluation (D0140), provided by a participating provider on March 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 9, 2022 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of 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 date of service January 24, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
June 9, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0149) and intraoral periapical x-ray 
(D0220) you received on May 16, 2022. 
 
You asked the Plan to pay for codes D0140 and D0220. You say that these services were needed on an 
emergency basis. The Plan denied your request. The Plan says these services are not covered under your dental 
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. The Plan only covers those dental services specifically listed in your 
dental benefits chart.  Codes D0140 and D0220 are not listed as covered dental services, regardless of whether 
or not the services were needed emergently. Therefore, we decided that the Plan does not have to pay for the 
limited oral exam (D0149) and intraoral periapical x-ray (D0220) you received on May 16, 2022.