Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom shoe inserts for date of service May 9, 2023. 
 
You asked the Plan to pay for the custom shoe inserts. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim was billed with an incorrect place of service. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the custom shoe inserts were billed with place of service 32 (nursing facility). Therefore, we 
decided that the Plan does not have to pay for the custom shoe inserts for date of service May 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on April 6, 2023, billed with 
codes 87150, 87481, 87798 and 87801. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on April 6, 2023, billed with codes 87150, 87481, 87798 and 87801.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11720 for date of service June 1, 2023. 
 
You asked the Plan to pay for procedure code 11720. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says a 0, 10 or 90-day post-operative procedure was not reported during its 
applicable post-operative period. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -79 should be used when identifying a 
unrelated procedure by the same physician during a postoperative period. 
 
 We looked at the file and Medicare rules. Review of the file shows that code 11720 was billed with modifier -
79. The documentation does not support that a 0, 10 or 90-day post-operative procedure was reported during its 
applicable post-operative period. As such, the billing rules for these services have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 11720 for date of service June 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87150 billed for February 2, 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 procedure code 87150 is not supported. 
 
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 87150 is culture, typing; identification by nucleic acid 
(DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed. 
 
We find that CPT code 87150 is not supported in the medical record. Specifically, the documentation does not 
support that identification by nucleic acid probe, amplified probe technique, per culture or isolate, was 
performed. 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 procedure code 87150 billed for 
February 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service March 14, 2023. 
 
You asked the Plan to pay for the billed services. You say that specimens are sent to the facility by physicians. 
The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
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 looked at the file and the rules. The medical documentation does not include an order that clearly 
documents the testing needed. There are also no medical records that document the intent for testing to be 
performed. Based on this information, we decided that Medicare rules for coverage of the billed services have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of 
service March 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J7120 billed for February 16, 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 code J7120 was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that drug codes are not billed for IV hydration 
services. 
 
We looked at the file and Medicare rules. The file shows that drug code J7120 was billed for IV hydration 
services. 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 procedure code J7120 billed for 
February 16, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammagard. 
 
You asked the Plan to pre-approve Gammagard. You say that this is medically necessary. The Plan denied your 
request. The Plan says this medication is not supported for use in diabetes. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Gammagard. Our reviewer says that the 
requested use of Gammagard is not medically necessary. Our physician reviewer found although the Plan has 
denied Gammagard stating that diabetes mellitus is not a medically accepted indication for the drug, the records 
show that the drug is actually being requested for "pre-transplant desensitization in highly sensitized patients 
awaiting kidney transplant." While this is a medically accepted indication for the drug, there is no 
documentation indicating why or how you are highly sensitized or evidence that you are awaiting a kidney 
transplant.  As such, the documentation does not support use of the drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gammagard have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gammagard.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (63650). 
 
You asked the Plan to pre-approve a spinal cord stimulator. 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 follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless all of the 
conditions have been 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 a spinal cord stimulator. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found there is no documentation of a 
surgical consultation or psychological evaluation. These criteria of the LCD are not met and therefore, the 
request is deemed 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 a spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator (63650).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 3, 2023. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on January 3, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 13, 2023. 
 
You asked the Plan to pay for OIVIT services. The Plan denied your request. The Plan says the billed services 
are not supported. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on March 13, 2023. 
 
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 a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. The lab panel in this case was billed with multiple codes, and not one 
unit of one code as required by LCA A58726.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 March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service May 8, 2023.  
 
You asked the Plan to pay for procedure code 99232. You say that 99232 should be paid as billed because it is 
supported in the documentation. The Plan denied your request. The Plan says payment for code 99232 is 
bundled into payment for code 99223. 
 
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 confirmed that both 99232 and 99223 were billed on the same day by a physician of the same 
specialty in the same billing group, which is considered the same provider. We have confirmed that code 99232 
is a column two code to column one code 99223 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99232 billed for date of service May 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS device. 
 
You asked the Plan to pre-approve the device. You say that the enrollee needs this device and procedure due to 
his worsening heart failure. The Plan denied your request. The Plan says there is no indication that this enrollee 
is enrolled in a clinical trial of the device. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the review indicates that the CardioMEMS device has been determined to be of uncertain value in 
the most recent 2022 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines 
and carries a risk of significant complications including death and sever pulmonary artery damage. The 
enrollee is no enrolled in a clinical trial. The requested CardioMEMS is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CardioMEMS device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 29, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. 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 September 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on April 13, 2023, and billed with codes 87150, 87481, 87641, 87653, 87798, and 87801. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
testing provided on April 13, 2023, and billed with codes 87150, 87481, 87641, 87653, 87798, and 87801.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 9, 2023, billed with 
codes 81216, 81223, 81238, 81241, 81242, 81249, 81250, 81279, 81298, 81305, 81307, 81311, 81317, 81320, 
81321, 81334, 81339, 81345, 81209. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have attached the additional 
documents to support the claim. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 9, 2023, billed with codes 81216, 81223, 81238, 81241, 81242, 81249, 81250, 81279, 81298, 81305, 
81307, 81311, 81317, 81320, 81321, 81334, 81339, 81345, 81209.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on June 21, 2023, and billed with codes 87481, 87653, 87798, and 87801. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
testing provided on June 21, 2023, and billed with codes 87481, 87653, 87798, and 87801.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on November 17, 2022. 
 
You asked the Plan to pay for the panel. 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 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 genetic testing 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 November 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 19, 2023, billed with 
codes 81225, 81328 59, 81335 59, 81479 GY 59, 81238 59, 81226, 81227 59, 81231 59, 81232 59, 81240 59, 
81241 59, 81291 59, 81306 59. 
 
You asked the Plan to pay for the genetic testing billed. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 19, 2023, billed with codes 81225, 81328 59, 81335 59, 81479 GY 59, 81238 59, 81226, 81227 59, 81231 
59, 81232 59, 81240 59, 81241 59, 81291 59, 81306 59.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 23, 2023, billed with 
codes 81410 and 81411. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 23, 2023, billed with codes 81410 and 81411.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88188 billed for date of service May 10, 
2023. 
 You asked the Plan to pay for procedure code 88188. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 88188 is bundled into payment for code 88189. 
 
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 88188 
is a column II code to column I code 88189. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 88188 billed for date of service May 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for lab services provided on June 26, 2023. 
 
You asked the Plan to waive the coinsurance for lab services. You say that you have never had to pay for blood 
work in the past. 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 30% 
coinsurance for point of service (POS) coverage, including lab services. 
 
You have been asked to pay 30% coinsurance for lab services. This item/service falls within the point of 
service (POS) coverage, including lab services 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. The total you owe is $81.06 ($270.24 allowed amount x 30% = $81.06 rounded down). Therefore, we decided that the Plan does not have to waive the coinsurance for lab 
services provided on June 26, 2023.