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

 
We decided that the Plan does not have to pay for lab services provided on May 29, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 29, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination (x-ray) of the mandible, teeth, 
spine, and cervical billed with codes 72040, 74230, 70100, and 70310 provided on April 18, 2023. 
 
You asked the Plan to pay for the x-rays. You say that codes 72040, 74230, 70100, and 70310 were billed 
correctly and should be paid. The Plan denied your request. The Plan says POS 11 (office setting) was billed, 
however, documentation received does not support that the services were performed in an office setting but 
rather in a mobile setting. 
 
Medicare rules say that for services in a mobile unit, the POS code assigned should either be the POS code for 
the entity the mobile unit is serving, or POS code 15. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the 
radiologic examination (x-ray) of the mandible, teeth, spine, and cervical billed with codes 72040, 74230, 
70100, and 70310 provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical medicine and rehabilitation provided on May 10, 
2023. 
 
You asked the Plan to pay for physical medicine and rehabilitation. You say that the services were medically 
necessary. 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 physical medicine and 
rehabilitation provided on May 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service April 10, 
2023.  
 You asked the Plan to pay for procedure code 88374. You say that please let the attached documentation serve 
to support medical necessity of the testing performed. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 88374 is 5. The MAI value for this code is 2. You billed 15 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 88374 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88374 billed for date of service April 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on July 1, 2023. 
 
You asked the Plan to pay for the anesthesia services. You say that another claim billed with these same 
diagnosis codes was paid. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot 
be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that I73.9 has an Excludes1 note in relation to I96. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay 
for anesthesia services provided on July 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on December 13, 2022. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The lab panel in this case was billed with multiple codes and not one 
code as required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab panel 
provided on December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 10, 2023, billed with 
procedure code 80053. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that the billing provider did not match the provider 
who reportedly performed the service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 80053 is comprehensive metabolic panel This panel must 
include the following: Albumin (82040) Bilirubin, total (82247) Calcium, total (82310) Carbon dioxide 
(bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphatase, alkaline (84075) 
Potassium (84132) Protein, total (84155) Sodium (84295) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) Urea nitrogen (BUN) (84520). 
 
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 practitioner services provided. Our reviewer says that the 
provided records document a Complete Metabolic Panel was performed by SRB, Stone Diagnostics. Records 
report the billing provider as Stone Clinical Laboratories of FL. Provided records do not clarify this disparity, 
thus the accuracy of the billed service 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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on April 10, 2023, billed with procedure code 
80053.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the pneumatic compression device (E0675). 
 
You asked the Plan to pay for  the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
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, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for  the pneumatic compression device (E0675).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmological services provided on 
June 01, 2023. 
 
You asked the Plan to waive the copayment for ophthalmological services. You say that you are requesting 
reconsideration for the denied claim. 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 $50.00 
copayment for vision care. 
 
You have been asked to pay a $50.00 copayment for ophthalmological services. This item/service falls within 
the 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 copayment for ophthalmological services 
provided on June 01, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the screening services coded as Q0091, G0101, and 
G0145 billed for date of service May 25, 2023. 
 
You asked the Plan to hold you harmless for the screening services. You say that the screening services should 
be covered as billed because you have been informed you are at a high risk of cervical cancer and similar 
screenings 3-6 months apart have been covered in the past. The Plan denied your request. The Plan says that 
the screening services are denied because they were coded by the provider with diagnoses indicating you are 
non-high risk, therefore screening services are only covered every 24 months. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the screening services by a contract provider. The file does not show that the Plan 
provided notice that the screening services would not be covered. Under Medicare rules, this means the 
screening services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you 
harmless for the screening services coded as Q0091, G0101, and G0145 billed for date of service May 25, 
2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance billed with code A4239 for date of 
service April 14, 2023. 
 
You asked the Plan to pay for the supply allowance. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the submitted records do not include an enrollee receipt or proof of delivery of the supplies on the 
billed date of service. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the supply 
allowance billed with code A4239 for date of service April 14, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve low frequency, non-contact, non-thermal ultrasound (97610). 
 
You asked the Plan to pre-approve low frequency, non-contact, non-thermal ultrasound. You say that the 
services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that low frequency, non-contact, non-thermal ultrasound 
is covered when specific criteria are met. 
 
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 low frequency, non-contact, non-
thermal ultrasound. Our reviewer says that the services are medically necessary. Our physician reviewer found 
the enrollee meets coverage detailed in the LCD due to lack of wound healing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of low frequency, non-contact, non-thermal ultrasound have been met. Therefore, 
we decided that the Plan has to pre-approve low frequency, non-contact, non-thermal ultrasound (97610).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records do not show a need for continued treatments that can only be 
given in a hospital setting. 
 
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 that in this case the enrollee was admitted acute metabolic encephalopathy in the 
setting of bacteremia and hypertensive urgency and has had a complicated hospital course. The record indicates 
that the enrollee has ongoing acute medical issues and still requires acute care services.  The enrollee continues to receive acute care services and these have not been denied. The medical record does 
not indicate that the enrollee requires services that she is not currently receiving but that would be available at 
the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be 
recommended. 
 
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 admission to a long term acute care hospital (LTACH).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary breast cancer-related disorders panel testing 
(81432) provided July 17, 2023. 
 You asked the Plan to pay for the genetic testing. You say that you would like this to be covered because you 
feel this testing was very much needed The Plan denied your request. The Plan says under Medicare guidelines, 
this request is 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 looked at the file and Medicare rules. The records show that the enrollee does not have any diagnosis of 
cancer. 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 hereditary breast cancer-related 
disorders panel testing (81432) provided July 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae Aortopathy comprehensive panel (81410, 81411) 
provided July 11, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that the physician ordered genetic testing for the 
enrollee due to its validated clinical utility in clarifying disease risk. The Plan denied your request. The Plan 
says this test is not covered by Medicare. 
 
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. Procedure codes 81410 and 81411 are listed under Group 3 
paragraph, Tier 1 non-covered codes. Also, per DEX Diagnostics, this test is not covered by Medicare. Based 
on this information, we decided that Medicare rules for coverage of the laboratory testing. have not been met. 
Therefore, we decided that the Plan does not have to pay for the Invitae Aortopathy comprehensive panel 
(81410, 81411) provided July 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 25, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services were medically necessary. 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 an office visit provided 
on April 25, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Transcranial Magnetic Stimulation (TMS). 
 
You asked the Plan to pre-approve TMS. You say that TMS is medically necessary. The Plan denied your 
request. The Plan says TMS does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that TMS is covered when the criteria listed in the 
Medicare rules section of this decision are met. 
 
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 TMS. Our reviewer says that the 
requested TMS is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that based on the information provided, this patient does not meet the clinical criteria for the use of 
repetitive Transcranial Magnetic Stimulation (rTMS) therapy as she has not undergone a complete medical trial 
and there is no documentation of the patient undergoing electroconvulsive treatment (ECT) or an inability for 
that procedure. There is no documentation of this procedure being ordered by a doctor of medicine (M.D.) or a 
Doctor of Osteopathic Medicine (D.O.). There is no documentation of this patient having undergone this 
procedure of repetitive Transcranial Magnetic Stimulation (rTMS) previously. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TMS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve TMS.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound panel rendered on March 7, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that multiplex tests must be billed with only one testing 
code. 
 
We looked at the file and Medicare rules. The file shows that the panel was not billed with one single testing 
code. 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 pay for the wound panel rendered on March 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight Psychotropic testing (81479) provided on 
September 22, 2022. 
 
You asked the Plan to pay for GeneSight Psychotropic testing. You say that this claim was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this test is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a reimbursement rate and a unique test identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of GeneSight Psychotropic testing have not been met. Therefore, we decided that 
the Plan does not have to pay for GeneSight Psychotropic testing (81479) provided on September 22, 2022.