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

 
We decided that the Plan does not have to pay for Human Papillomavirus (HPV) testing (87624) billed for date 
of service October 20, 2021. You asked the Plan to pay for HPV testing. You say that these services were ordered by a physician and were 
medically necessary. The Plan denied your request. The Plan says they reached out to the provider listed as the 
ordering physician in this case and found that the listed physician did not order this testing. Therefore, these 
services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. Medicare rules also say that while a physician order is not required to be 
signed, the physician must clearly document, in the medical record, his or her intent for the test to be 
performed. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of HPV testing have been met. 
Specifically, there is no signed physician order included in the file. In addition, there are no medical records or 
progress note dated prior to testing which show that this physician is treating the enrollee and intended for this 
test to be performed. Therefore, this test cannot be verified as medically reasonable and necessary. Therefore, 
we decided that the Plan does not have to pay for Human Papillomavirus (HPV) testing (87624) billed for date 
of service October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for dental services provided by an out-of-network dentist 
 
You asked the Plan to reimburse for the dental services. You say that the services should be reimbursed as you 
disagree with the denial and prefer to see the out-of-network 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 reimburse for dental services provided by an out-of-network dentist
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says IRF services are not 
medically necessary or appropriate. 
 
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 complexity of your nursing medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer also found 
that you do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program at least three hours a day and five days a week, or 15 
hours over seven consecutive days. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0657).

You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically
necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. Records do not show lymphedema extending to the abdomen, chest, or trunk. Therefore, we decided
that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0657).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88361, 88312, 88305 and 88112 billed for 
date of service February 9, 2022. 
 
You asked the Plan to pay for codes 88361, 88312, 88305 and 88112. You say that these services were 
necessary and were performed by the only laboratory who can provide these services. The Plan denied your 
request. The Plan says these services were not billed in accordance with Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that CPT codes 88361, 88312, 88305 and 88112 are pathology services which have both professional 
components (PC) and technical components. These services were not billed with modifier 26 to indicate that 
only the professional component payment is requested. This means that payment is requested for both the PC 
and TC of these services. However, these services were provided to an enrollee who was in an outpatient 
hospital setting at the time the sample was collected, which means that the TC component is bundled into the 
facility payment. The TC portion of these services are not separately payable, and therefore these services are 
not supported as billed. Based on this information, we decided that Medicare rules for coverage of codes 
88361, 88312, 88305 and 88112 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 88361, 88312, 88305 and 88112 billed for date of service February 9, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic activities (97530) and neuromuscular 
reeducation (97112) provided on January 31, 2022. 
 
You asked the Plan to pay for codes 97530 x 2 and 97112 x2 provided on January 31, 2022. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
medical records support the billing of code 97530 x2 on February 2, 2022, February 4, 2022, and February 9, 
2022. The Plan says that the medical records support the billing of code 97112 x2 on February 2, 2022, 
February 4, 2022, and February 9, 2022. The Plan says that the medical records do not support the billing of 
codes 97530 x2 and 97112 x2 on January 31, 2022. 
 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 97530 is Therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. The definition 
of code 97112 is Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of 
movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing 
activities. 
 
We find that CPT codes 97530 and 97112 are not supported in the medical record for the January 31, 2022, 
date of service. Specifically, the records for the January 31, 2022, date of service do not note that that these 
services were provided on this day. Based on this information, we decided that Medicare rules for coverage of 
codes 97530 x 2 and 97112 x2 provided on January 31, 2022, have not been met. Therefore, we decided that 
the Plan does not have to pay for the therapeutic activities (97530) and neuromuscular reeducation (97112) 
provided on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain crowns (D2740 x2) provided by a network 
provider on February 10, 2022. 
 
You asked the Plan to pay for the porcelain crowns (D2740 x2). You say that the dental work was not cosmetic 
and tooth health is preventive for cardiovascular disease. You say you would like the Plan to pay for the 
crowns. The Plan denied your request. The Plan says the enrollee has met the $2,000 allowance. 
 
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 crowns (D2740 x2) are not among 
those covered under this benefit. The record shows you met your $2,000 allowance on February 10, 2022, 
which means you are responsible for the remaining amount. Therefore, we decided that the Plan does not have 
to pay for the porcelain crowns (D2740 x2) provided by a network provider on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on May 12, 2022. 
 
You asked the Plan to pay for a limited oral evaluation - problem focused (D0140). You say that you are 
requesting an appeal for the denial of the dental service. The Plan denied your request. The Plan says this 
service is not covered under the benefit package. 
 
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 a limited 
oral evaluation - problem focused (D0140) provided on May 12, 2022.  
 Please note, that this decision is only in regards to the oral evaluation (D0140) provided on May 12, 2022. 
Please contact the Plan for more information about appeals for any other items or services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the IRF services you 
are requesting do not meet the requirements for approval. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. Our reviewer also found that there is no indication that 
the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a 
week, under the supervision of a physician with at least 3 visits weekly to regain or maintain their functional 
status. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A4351 billed for date of service August 5, 2021. 
 
You asked the Plan to pay for code A4351. The Plan denied your request. The Plan says code A4351 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 code A4351 has a status indicator of P on the Physician Fee Schedule. This means that code 
A4351 is not separately payable. Based on this information, we decided that Medicare rules for coverage of code A4351 have not been met. Therefore, we decided that the Plan does not have to pay for code A4351 billed 
for date of service August 5, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 70551-26 billed for date of service March 9, 2022. 
 
You asked the Plan to pay for code 70551-26. You say that this claim denied in error. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 15, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for code 70551-26 have not been met. Therefore, 
we decided that the Plan does not have to pay for code 70551-26 billed for date of service March 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attendant control (E2331). 
 
You asked the Plan to pre-approve an attendant control. You say that this power wheelchair accessory is 
necessary. The Plan denied your request. The Plan says the criteria for coverage of this accessory have not been 
satisfied. 
 
The Plan must follow Medicare rules. Medicare rules say that an attendant control is covered in place of a 
beneficiary-operated drive control system if the beneficiary meets coverage criteria for a wheelchair, is unable 
to operate a manual or power wheelchair and has a caregiver who is unable to operate a manual wheelchair but 
is able to operate a power wheelchair. 
 
We looked at the file and Medicare rules. In this case, the documentation confirms you are able to operate the 
requested power wheelchair. Based on this information, we decided that Medicare rules for coverage of an 
attendant control have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
attendant control (E2331).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC panel provided to the enrollee on May 
12, 2022. 
 
You asked the Plan to pay for the DecisionDx-SCC panel. You say that this claim should be paid. The Plan 
denied your request. The Plan says that further investigation is needed to establish such testing as the standard 
of care in managing cutaneous squamous cell carcinoma. 
 
The Plan follows Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, the 
MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary 
requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage 
status is listed in the DEXTM Diagnostics Exchange. The Arizona LCD was used as the testing was performed 
in Arizona. 
 We looked at the file and Medicare rules. We found that the DecisionDx-SCC panel is listed as noncovered in 
the DEX database. Based on this information, we find that the Medicare coverage rules for the DecisionDx-
SCC panel have not been met. Therefore, we decided that the Plan does not have to pay for the DecisionDx-
SCC panel provided to the enrollee on May 12, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve continued SNF care. You say that the enrollee is only at 30% function and 
would benefit more from the extensive therapy provided in a SNF. The Plan denied your request. The Plan says 
because the continued SNF care is not medically necessary, and the enrollee is safe to discharge home. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 continued SNF care. Our reviewer says 
that the requested SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found based on the limited documentation provided, the enrollee no longer 
qualifies for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does 
not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve periodontal scaling and root planing (D4341) provided by a 
participating provider. 
 
You asked the Plan to pre-approve periodontal scaling and root planing. You say that you would like the Plan 
to pay for this. The Plan denied your request. The Plan says that D4341 is not medically necessary. 
 
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 Plan covers periodontal 
scaling and root planing when the services are medically necessary and reasonable. 
 
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 periodontal scaling and root planing. 
Our reviewer says that D4341 is not medically necessary. Our physician reviewer found the documentation 
provided meets the criteria for covered periodontal scaling and root planing in four quadrants. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of periodontal scaling and root planing have been met. Therefore, we decided that 
the Plan has to pre-approve periodontal scaling and root planing (D4341) provided by a participating provider. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the replacement of semi-precision attachment (D5867) 
provided by a participating provider. 
 
You asked the Plan to pre-approve the replacement of semi-precision attachment. You say that you would like 
the Plan to approve these services. The Plan denied your request. The Plan says the requested dental work 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 pre-approve the 
replacement of semi-precision attachment (D5867) provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae Multi-Cancer Panel billed with codes 81317, 
81292, 81298, 81295, 81300, 81297, 81319, and 81294 for date of service April 11, 2022. 
 You asked the Plan to pay for codes 81317, 81292, 81298, 81295, 81300, 81297, 81319, and 81294. You say 
that the records provided support the medical necessity of the services in dispute. The Plan denied your request. 
The Plan says screening services such as pre-symptomatic genetic tests and services used to detect an 
undiagnosed disease or disease predisposition are not a Medicare benefit and are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Records show that the tests in dispute were requested solely for family history and not due to signs or 
symptoms of cancer. The test at issue in this appeal, the Invitae Multi-Cancer Panel, was requested solely for 
screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided 
that the Plan does not have to pay for the Invitae Multi-Cancer Panel billed with codes 81317, 81292, 81298, 
81295, 81300, 81297, 81319, and 81294 for date of service April 11, 2022.