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

 
We decided that the Plan has to pay for testing services provided on April 10, 2023, billed with procedure 
codes 95938-26, 95939-26, 95937-26, 95870-26, and G0453. 
 
You asked the Plan to pay for the testing services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that the provider should bill the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that carriers may not pay for the technical component 
(TC) of radiology services furnished to hospital inpatient patients.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing services provided have been met. Though it is true that the TC cannot be paid in the 
facility setting, the documentation shows that only the professional component was billed.  Therefore, we 
decided that the Plan has to pay for testing services provided on April 10, 2023, billed with procedure codes 
95938-26, 95939-26, 95937-26, 95870-26, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0318 for date of service May 5, 2023. 
 
You asked the Plan to pay for procedure code G0318. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable 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 G0318 is not payable as billed. Specifically, code G0318 was billed with code 99350 on 
the same date of service, for the same condition, by the same specialty in the same group practice. This means 
this code is not separately payable as billed. Based on this information, we decided that Medicare rules for 
coverage of procedure code G0318 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code G0318 for date of service May 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular genetics; DNA probe, each (eg. FISH) (88271) 
Molecular genetics; interphase in Situ hybridization, analyse 100-300 cells (88275) provided February 8, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that please review the included medical 
documentation that supports medical necessity for the rendered services. The Plan denied your request. The 
Plan says these services are not authorized because codes 88271 and 88275 are not Medicare covered benefits 
for the diagnoses listed on the claim. 
 
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 genetic testing. 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 right lung cancer and pre-diabetes. The 
services are not authorized because codes 88271 and 88275 are not Medicare covered benefits for the 
diagnoses listed on the claim. The review has determined that the items/services at issue in this case are not 
medically 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 the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the molecular genetics; DNA probe, each (eg. FISH) (88271) Molecular genetics; 
interphase in Situ hybridization, analyse 100-300 cells (88275) provided February 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for eye surgery on February 23, 2023, to March 
02, 2023. 
 
You asked the Plan to waive the cost share for eye surgery. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly.  
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 $245 
copayment for surgery services at ambulatory surgical center. You must pay a $25 copayment for Medicare 
covered vision services at a specialist's office. Covered services include outpatient physician services for the 
diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular 
degeneration. Original Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts. 
There was a $405.47 deductible + $25 copayment + $102.35 deductible + $245 copayment + $167.18 
deductible + $245 copayment = $1,190. Therefore, results in the total cost sharing amount of $1,190. 
 
You have been asked to pay a $1,190 cost share for eye surgery. This item/service falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers and vision 
care benefit category. 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 waive the cost share for eye surgery on February 23, 2023, 
to March 02, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services reported with DRG 356 rendered 
from August 29, 2022, September 8, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the clinical documentation does not support 
that the following diagnosis impacted this hospital admission - G93.41- metabolic encephalopathy. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 356. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that there is no evidence that metabolic encephalopathy occurred during or affected the hospitalization. As 
such, the billing of G93.41 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services reported with DRG 356 rendered from August 29, 2022, September 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Liquid Biopsy CGP Panel testing (81455) 
provided February 27, 2023. 
 
You asked the Plan to pay for the genetic panel. You say that the doctor regarded this test as a medically 
necessary and valuable tool when determining treatment for the enrollee. The Plan denied your request. The 
Plan says this test is not FDA approved. 
 
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. Tempus xF has not had FDA approval or clearance as a companion 
in vitro diagnostic or an FDA-approved or -cleared indication for use in this patients cancer. Based on this 
information, we decided that Medicare rules for coverage of the genetic panel have not been met. Therefore, we 
decided that the Plan does not have to pay for the Tempus Liquid Biopsy CGP Panel testing (81455) provided 
February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on March 1, 
2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says this test is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on March 1, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kanjinti (Q5117) and Opdivo (J9299). 
 
You asked the Plan to pre-approve Kanjinti and Opdivo. 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 may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Kanjinti and Opdivo. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the review has determined that the 
requested use of Kanjinti and Opdivo is not FDA-approved for the enrollees diagnosis. Its use is not supported 
by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kanjinti and Opdivo have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Kanjinti (Q5117) and Opdivo (J9299).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87486, 87498, 87502, 87541, 87581, 87633, 
87634, 87640, 87641, 87651, 87798, U0003, and U0005 for date of service December 14, 2022. 
 You asked the Plan to pay for 87486, 87498, 87502, 87541, 87581, 87633, 87634, 87640, 87641, 87651, 
87798, U0003, and U0005. You say that you disagree with the Plan's denial. The Plan denied your request. The 
Plan says the services are not payable 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 codes 87486, 87498, 87502, 87541, 87581, 87633, 87634, 87640, 87641, 87651, 87798, 
U0003, and U0005 are not supported in the medical record. Specifically, the documentation shows that a Covid 
Respiratory Plus Panel was provided. It is inappropriate to bill individual CPT codes for the testing panel 
provided. There is a more appropriate code to be billed for the services rendered. Based on this information, we 
decided that Medicare rules for coverage of 87486, 87498, 87502, 87541, 87581, 87633, 87634, 87640, 87641, 
87651, 87798, U0003, and U0005 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 87486, 87498, 87502, 87541, 87581, 87633, 87634, 87640, 87641, 87651, 87798, U0003, 
and U0005 for date of service December 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service May 21, 
2022, to June 15, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service May 21, 2022, to June 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the required care cannot be managed at a 
lower level of care and risks further deterioration if not approved for LTACH. The Plan denied your request. 
The Plan says the enrollee is receiving the appropriate care and does not require transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that the enrollee requires services that they are 
not currently receiving. The enrollee still requires acute care services before transitioning to a lower 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cervical or vaginal cancer screening for an encounter of 
gynecological exam provided on February 9, 2023 
 
You asked the Plan to pay for the cervical or vaginal cancer screening for an encounter of gynecological exam. 
The Plan denied your request. The Plan says the benefit has been exhausted. 
 
The Plan contract says that Pap tests and pelvic exams are covered once every 2 calendar years. 
 
We looked at the file and the Plans rules. The file shows that your previous screening was less than 2 years 
ago on September 23, 2021. Based on this information, we decided that the Plans rules for coverage of the 
cervical or vaginal cancer screening for an encounter of gynecological exam have not been met. Therefore, we 
decided that the Plan does not have to pay for a cervical or vaginal cancer screening for an encounter of 
gynecological exam provided on February 9, 2023
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a PILD procedure (0275T) provided on December 13, 2022. 
 
You asked the Plan to pay for a PILD procedure. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that hospital outpatient facilities shall bill for PILD 
procedure code 0275T or procedure code G0276 for LSS on a 13X or 85X TOB. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a PILD procedure have not been met. Specifically, the case record shows that the claim was not 
billed on a 13X or 85X TOB. Therefore, we decided that the Plan does not have to pay for a PILD procedure 
(0275T) provided on December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a sleep study (procedure code 95800) rendered from March 
3, 2023, to March 4, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is a more appropriate code to use for the services 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 95800 is "Sleep study, unattended, simultaneous 
recording; heart rate, oxygen saturation, respiratory analysis (eg, by airflow or peripheral arterial tone), and 
sleep time." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report describes a 
sleep study performed in the home setting.  In this case, the G0399 code is reported when services are 
performed in the home, and 95806 is reported when services are performed in a facility.  An incorrect 
procedure code was reported for an in-home sleep study. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a sleep study (procedure code 95800) rendered from March 3, 2023, to March 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic test (81479) provided November 
21, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the GeneSight test was denied on the basis 
that the procedure code is purportedly invalid, which you believe to be erroneous. The Plan denied your request. The Plan says this test in considered experimental and investigational as GeneSight Psychotropic has 
not been shown to be useful. 
 
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. The test is not covered by Medicare per the DEX Diagnostics 
Exchange Registry. 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 GeneSight 
Psychotropic test (81479) provided November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Juven therapeutic nutrition drink mix powder for wound 
healing support (A9999) purchased April 6, 2023, to April 17, 2023.  
 
You asked the Plan to pay for the therapeutic drink . You say that you are asking for an appeal as this was 
essential to your wound care and healing. The Plan denied your request. The Plan says this item is not covered 
and was purchased from a supplier that does not participate with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the Juven therapeutic nutrition drink mix 
powder for wound healing support (A9999) purchased April 6, 2023, to April 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87798, and 87481 for date of service 
April 13, 2023. 
 
You asked the Plan to pay for procedure codes 87150, 87798, and 87481. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services are not payable 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 codes 87150, 87798, and 87481 are not payable as billed. Specifically, a test panel cannot be 
unbundled and billed as individual components regardless of the fact that the test reports multiple individual 
pathogens and/or targets. The unbundling of the codes billed is not appropriate. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 87150, 87798, and 87481 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87150, 87798, and 87481 for date 
of service April 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 08, 2023. 
 
You asked the Plan to pay for the home visit. You say that when checking this code you were told there was no 
action needed. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit provided 
on March 08, 2023.