Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the drug testing provided on May 30, 2017.
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the documentation submitted does not support the service 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. In this case, the CPT Code Manual definition of code G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. We find that CPT code G0482 is supported in the medical record. Specifically, the lab report clearly shows that 15-21 drug classes were tested in this case. Please note, we counted the classes based on the separately billable tests from the CPT Handbook. Additionally, the Plan has not forwarded any evidence to support why CPT code 80307 is not eligible for payment. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. Also, the record indicates that this provider was directed by the Plan to not obtain records. With this direction, it is inappropriate for the Plan to deny these services based on the physician signature. Based on this information, we decided that Medicare rules for coverage of the drug testing have been met. Therefore, we decided that the Plan has to pay for the drug testing provided on May 30, 2017.
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 genetic testing (0037U) provided December 15, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says this testing panel is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that panels that include the FANCC gene are non-
covered. 
 
We looked at the file and Medicare rules. The panel included FANCC gene testing and is non-covered. Based 
on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for genetic testing (0037U) provided December 15, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 14, 2022. 
 
You asked the Plan to pay for the services provided. You say that the pathology report provides evidence of 
medical necessity. The Plan denied your request. The Plan says the services were reported without a required 
modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
 We looked at the file and the rules. The file shows that the enrollee was part of a clinical trial. The claim 
provided does not show that the services were billed per guidelines. 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 the lab services provided on February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on April 26, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an 
appropriate modifier is required. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We looked at the file and the rules. We find that CPT code 00560 was not billed with a modifier suitable for 
payment. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on April 26, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drugs dispensed in the office (D9630) provided on 
November 9, 2021. 
 
You asked the Plan to pay for drugs dispensed in the office. You say that the dentist was in-network, and the 
claim was not processed correctly. The Plan denied your request. The Plan says drugs dispensed in the office 
(D9630) are not covered by your supplemental dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 
drugs dispensed in the office (D9630) provided on November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010) provided by a 
participating provider. 
 
You asked the Plan to pre-approve an endosteal implant. You say that you cannot eat properly. The Plan denied 
your request. The Plan says implants are not covered. 
 
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 pre-approve an 
endosteal implant (D6010) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adjunctive pre-diagnostic test (D0431) provided by an out-
of-network provider on February 10, 2022. 
 
You asked the Plan to pay for adjunctive pre-diagnostic test. You say that these services were medically 
necessary. The Plan denied your request. The Plan says D0431 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 
adjunctive pre-diagnostic test (D0431) provided by an out-of-network provider on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0220) and additional intraoral x-rays 
(D0230) provided on February 8, 2022. 
 
You asked the Plan to pay for x-rays. You say that annual dental x-rays were included in the dental plan. The 
Plan denied your request. The Plan says intraoral x-ray (D0220) and additional intraoral x-rays (D0230) are not 
covered by your routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 an 
intraoral x-ray (D0220) and additional intraoral x-rays (D0230) provided on February 8, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (93310) provided October 
13, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that you use your best efforts to submit your 
claim in a timely manner and seldom file them outside the filing limit. You depend on the facility for timely 
notification of patients health insurance coverage. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent nursing facility care (93310) provided October 
13, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
February 7, 2022, to February 10, 2022. 
 
You asked the Plan to pay for the services provided. You say that the correct bill type was submitted. The Plan 
denied your request. The Plan says the claim cannot be reprocessed until a correct claim is received. 
 
The Plan must follow Medicare rules. The rules say that any claim with incomplete, missing, or invalid 
information for all of these elements may be returned as unprocessable. 
 
We looked at the claim submitted, the file and the Medicare rules. The claim provided was not billed with a 
Type of Bill suitable for payment. Based on this information, we decided that Medicare rules for completing 
the claim for the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the home health services provided to the enrollee from February 7, 2022, to February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx- Melanoma testing provided on January 10, 
2022. 
 
You asked the Plan to pay for the DecisionDx- Melanoma testing. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
The Plan follows Medicare rules. Medicare rules say that DecisionDx- Melanoma testing is covered when the 
enrollee has Stage T1b and above and has T1a with documented concern about adequacy of microstaging. 
 
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 DecisionDx- Melanoma testing. Our 
reviewer says that the documentation does not support that Our physician reviewer found the enrollee has a 
diagnosis reported as malignant melanoma of left upper limb, including shoulder. The enrollee had primary 
tumor stage T1a disease. The above cited LCD requires enrollees with Stage T1a have "documented concern 
about adequacy of microstaging". The LCD also states the presumed risk for a positive sentinel lymph node 
biopsy based on clinical, histological, or other information is greater than 5%. Per the eighth edition American 
Joint Committee on Cancer (AJCC) melanoma staging system, this enrollee has T1a melanoma, based on the 
thickness of the primary tumor of less than 0.8 millimeters and the absence of primary tumor ulceration. In the 
absence of regional or distant metastases, this enrollee would therefore be classified as having clinical Stage IA 
disease. The review has determined that the enrollee has a personal history of melanoma. The enrollee does not 
meet i. or ii. criteria of the LCD. Therefore, the services rendered are not a covered benefit. 
 
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 DecisionDx- Melanoma testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the DecisionDx- Melanoma testing provided on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150). 
 
You asked the Plan to pre-approve an evaluation. You say that you disagree with the denial for dental services. 
The Plan denied your request. The Plan says the services are not covered when seen by an out-of-network 
provider. 
 
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 when received by an out-of-network provider. Therefore, we decided 
that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the selective catheter placement (36227) provided on January 
24, 2022. 
 
You asked the Plan to pay for the selective catheter placement (36227). You say that CPT code 36227 is an add 
on code supported by the records. The Plan denied your request. The Plan says procedure codes 36226, 36223 
and 76377 were approved. The Plan also says procedure code 36227 is not supported by the medical records 
submitted. 
 
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 36227 is selective catheter placement, external carotid 
artery, unilateral, with angiography of the ipsilateral external carotid circulation and all associated radiological 
supervision and interpretation (List separately in addition to code for primary procedure). 
 
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 selective catheter placement (36227). Our reviewer says 
that the documentation was reviewed and does not meet the criteria for coverage. Our reviewer found the 
procedure report does include enough documentation to a confirm catheter placement. The medical record does 
not include documentation to confirm a selective angiography including the physician manipulating the 
catheter to the external carotid artery per the NCCI Policy Manual. 
 
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 selective catheter placement (36227) have not been met. Therefore, we 
decided that the Plan does not have to pay for the selective catheter placement (36227) provided on January 24, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam CT capture (D0365, D0366, and D0367) 
provided by a participating provider. 
 
You asked the Plan to pre-approve a cone beam CT capture. You say that these services are medically 
necessary. The Plan denied your request. The Plan says the requested services are not covered. 
 
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 pre-approve a 
cone beam CT capture (D0365, D0366, and D0367) provided by participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction of tooth #13 (D7140) provided on April 26, 2022. 
 
You asked the Plan to pay for an extraction. You say that you were in severe pain and these charges should be 
covered. The Plan denied your request. The Plan says extractions (D7140) are not covered by your 
supplemental dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 an 
extraction of tooth #13 (D7140) provided on April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft (D3428). 
 
You asked the Plan to pre-approve a bone graft. You say that you need a bone graft because you do not have a 
tooth to hold up the crown and it is going to affect your sinuses. The Plan denied your request. The Plan says a 
bone graft (D3428) is not covered by 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. Therefore, we decided that the Plan does not have to pre-approve a 
bone graft (D3428).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 9, 2021. 
 
You asked the Plan to pay for the lab services. You say that different panels serve different purposes. The Plan 
denied your request. The Plan says an appropriate modifier was not 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.  In this case, we have confirmed that code 88187 is a column II code to column I code 88189. The service at 
issue 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 the 
lab services provided on December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and an extraction 
(D7210), provided by a participating provider. 
 
You asked the Plan to pre-approve a maxillary partial denture and an extraction. You say that you would like 
the Plan to approve this dental work. The Plan denied your request. The Plan says the requested services are not 
covered. 
 
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 pre-approve a 
maxillary partial denture (D5213) and an extraction (D7210), provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dialysis services (90999, J0887) provided December 2, 2021 
to December 30, 2021. 
 
You asked the Plan to pay for the dialysis services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid 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 find that CPT code 90999, & J0887 is not supported in the medical record. Specifically, the claim did not 
include the required "G" modifier. Based on this information, we decided that Medicare rules for coverage of 
the dialysis services have not been met. Therefore, we decided that the Plan does not have to pay for dialysis 
services (90999, J0887) provided December 2, 2021 to December 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted musculoskeletal system procedure (20999) 
provided on December 15, 2021. 
 
You asked the Plan to pay for the unlisted musculoskeletal system procedure (20999). You say that code 20999 
was performed in a separate incision for an exchange of subtalar joint screws. You say that this is coded 
correctly, and the records support the billing. The Plan denied your request. The Plan says procedure codes 
27702, 20680 and 28306 were approved and procedure code 20999 is not supported by the medical records 
submitted. 
 
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 20999 is unlisted procedure, musculoskeletal system, 
general. 
 
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 unlisted musculoskeletal system procedure (20999). Our 
reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our 
reviewer found the operative report does not include documentation to confirm what procedure was performed 
and reported as unlisted musculoskeletal system. Therefore, the unlisted procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the unlisted musculoskeletal system procedure (20999) have not been met. 
Therefore, we decided that the Plan does not have to pay for the unlisted musculoskeletal system procedure 
(20999) provided on December 15, 2021.