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

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. 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 Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found single agent pembrolizumab is not 
indicated for the treatment of stage IIIB non-small cell lung cancer with a programmed cell death ligand 1 (PD-
L1) of 0%. Use is not FDA approved, supported by major drug compendia, or the medical literature. The 
service is not reasonable or medically 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA); 
candida species, amplified probe technique (87481) infectious agent detection by nucleic acid (DNA or RNA); 
Gardnerella vaginalis, amplified probe technique (87511) infectious agent detection by nucleic acid (DNA or 
RNA), not otherwise specified; amplified probe technique, each organism (87798) provided February 11, 2022. 
 You asked the Plan to pay for the laboratory services. You say that you are an independent diagnostic 
laboratory that tests pathology, medication management and toxicology samples sent from clinics and 
providers for patients they have determined require such testing. The Plan denied your request. The Plan says 
this service does not meet the medically necessary requirements and is excluded from coverage. 
 
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 laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee has a history of dementia, anemia, HTN, DM, 
CAD, HLD, and granuloma annulare. There was no specific clinical rationale for the requested lab studies. The 
review has determined that the use of 87481, 87511 and 87798 was not supported by the medical records. The 
records did not support that the services at issue in this case are medically reasonable or 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 the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for infectious agent detection by nucleic acid (DNA or RNA); candida species, amplified 
probe technique (87481) infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, 
amplified probe technique (87511) infectious agent detection by nucleic acid (DNA or RNA), not otherwise 
specified; amplified probe technique, each organism (87798) provided February 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88333 billed for date of service March 24, 
2022.  
You asked the Plan to pay for procedure code 88333. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 88333 is bundled into payment for code 88173. 
 
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 88333 
is a column II code to column I code 88173. 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 88333 billed for date of service March 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 14, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the shock absorber for manual wheelchair, each 
(E1015). 
 
You asked the Plan to pre-approve the shock absorber. You say please reconsider the documentation provided 
for the wheelchair and accessories that are medically necessary to meet the enrollees current needs. The Plan 
denied your request. The Plan says E1015 does not primarily serve a medical purpose and is for convenience 
and outdoor use. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that for equipment to be covered, it must primarily serve a medical 
purpose.   
 
We looked at the file and Medicare rules. The item at issue in this appeal does not serve a purpose that is 
primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of the shock absorber have not been met. Therefore, we decided that the Plan does not have to pre-approve the shock 
absorber for manual wheelchair, each (E1015).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4357 billed for date of service April 8, 
2022. 
 You asked the Plan to pay for procedure code A4357. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code A4357 is bundled into payment for code A4314. 
 
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 A4357 
is a column II code to column I code A4314 in the LCA cited above. 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 procedure code A4357 billed for date of service April 8, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a spring powered device (A4258) provided on June 5, 2022. 
 
You asked the Plan to pay for a spring powered device. You say that this is supported in the records. The Plan 
denied your request. The Plan says that the maximum limit for this item was exceeded. 
 
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 rules also say that more than one spring powered device (code A4258) per 6 months is not 
reasonable and necessary. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Although the Plan is correct that this item is limited to one unit every six 
months, the Plan has not provided any information or documentation showing when the enrollee was last 
supplied with a spring powered device, and only one unit was billed on this claim. Without this information, it 
cannot be confirmed that the maximum limit was exceeded. Therefore, we decided that the Plan has to pay for 
a spring powered device (A4258) provided on June 5, 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: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 95822. We decided that the Plan does not have to pay 
for procedure codes 95999 and G0453.  
 
You asked the Plan to pay for procedure codes 95822, 95999 and G0453 billed for date of service April 13, 
2022. You say that these services were necessary and are supported in the medical records. The Plan says that 
these services are not supported 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. 
 
We decided that the Plan has to pay for procedure code 95822.  
 
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 procedure code 95822. Our reviewer says 
that procedure code 95822-26-XU was reported appropriately. Our physician reviewer found that this service is 
supported in the technical report.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95822 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 95822.  
 
We also decided that the Plan does not have to pay for procedure codes 95999 and G0453. 
 
In this case, we have confirmed that code G0453 is a column II code to column I code 51785. 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 for code G0453. 
 
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 procedure code 95999. Our reviewer says 
that billing code 95999 is not supported in this case. Our physician reviewer found that this service is not 
supported in the medical records provided. In addition, two units of 95999 were billed, which exceeds the 
Medically Unlikely Edits (MUE) for this code.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 95999 and G0453 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 95999 and G0453. 
 
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 April 4, 2022, billed with 
codes 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81247, 81291, 81306, 81328, 81335, 81350, 
81355, 81238, 81406, 81381, and 81381-59. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed 
based on the medical records. 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 
April 4, 2022, billed with codes 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81247, 81291, 
81306, 81328, 81335, 81350, 81355, 81238, 81406, 81381, and 81381-59.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on July 23, 2022. 
 
You asked the Plan to pay for the core buildup. You say that you would like to appeal this service. The Plan 
denied your request. The Plan says this service is not included on your benefit plan, and is not a covered 
service. 
 
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 core 
buildup, including any pins when required (D2950) provided on July 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for measurement of post-voiding residual urine and/or bladder 
capacity by ultrasound, non-imaging (CPT code 51798) provided on July 15, 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 supported by the records. 
 
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 51798 is measurement of post-voiding residual urine 
and/or bladder capacity by ultrasound, non-imaging. 
 
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 service. Our reviewer found there is no documentation 
indicating that the measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-
imaging (CPT) code 51798) was provided on July 15, 2022. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging 
(CPT code 51798) provided on July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4342) on the 
lower right quadrant provided on September 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed the cleaning due to an abscess and 
recessed gum which is hard to keep clean. 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 June 14, 2022. Therefore, 
we decided that the Plan does not have to pay for the periodontal scaling and root planing (D4342) on the lower 
right quadrant provided on September 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a plastic standard side guard (K0108). 
 
You asked the Plan to pre-approve a plastic standard side guard. You say that please review the attached 
medical documentation to support the need of the custom medical equipment being requested. The Plan denied 
your request. The Plan says The plastic side guard does not primarily serve a medical purpose and is not 
considered to be durable medical equipment. 
 
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 a plastic standard side guard have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a plastic standard side guard (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service May 10, 
2022. 
 You asked the Plan to pay for procedure code 81345. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says payment for code 81345 is 
bundled into payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service May 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cerapedics i-Factor allograft. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is limited published, large-scale, 
long-term peer-reviewed literature that shows the allograft to be an effective and/or safe treatment for the 
enrollee's pathology. Further studies are needed to demonstrate this request has beneficial outcomes compared 
with conventional treatment. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception.  
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a Cerapedics i-Factor allograft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual therapy (97140), office visits (99211, 99212), 
and the extraspinal chiropractic manipulative treatment (98943) provided from April 26, 2022, through July 11, 
2022. Additionally, we decided that the Plan does not have to waive the copayments for the chiropractic 
manipulative treatments (98940, 98941) provided on April 26, 2022 and May 9, 2022. 
 
You asked the Plan to pay for the office visits, manual therapy, and the extraspinal chiropractic manipulative 
treatment. Additionally, you asked the Plan to waive the copayments for the chiropractic manipulative 
treatments provided. You say that you are requesting a reconsideration of the Plan's denial for payment. The 
Plan denied your request. The Plan says the services at issue are not covered by the Plan. Additionally, the Plan 
says that the copayments were applied correctly to the services provided.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. Additionally, the rules say that the Physician Fee 
Schedule Status Indicator N means that it is a non-covered service. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for each Medicare-covered visit.  
 
The records show that CPT codes 97140, 99211, 99212, and 98943 at issue are not covered by the Plan or by 
Medicare as they are not manual manipulation of the spine to correct a subluxation. CPT code 98943 has a 
status indicator of  N which specifically means it is not covered by Medicare. Additionally, the other three 
codes are not covered when provided by a chiropractor. Additionally, you were asked to pay $40 which 
includes a $20 copayment for the chiropractic manipulative treatments provided on April 26, 2022 and May 9, 
2022. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to pay for the manual therapy (97140), office visits (99211, 99212), and the 
extraspinal chiropractic manipulative treatment (98943) provided from April 26, 2022, through July 11, 2022. 
Additionally, we decided that the Plan does not have to waive the copayments for the chiropractic manipulative 
treatments (98940, 98941) provided on April 26, 2022 and May 9, 2022.