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

 
We decided that the Plan does not have to pay for procedure code 81345 billed for March 1, 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 81345 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 81345 is TERT (telomerase reverse transcriptase) (eg, 
thyroid carcinoma, glioblastoma multiforme) gene analysis, targeted sequence analysis (eg, promoter region). 
 
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 these services. Our reviewer says that procedure code 81345 
is not supported. Our reviewer found the submitted laboratory report does not include documentation of TERT 
testing. The procedure is not found in any of the reports. Code 81345 is therefore not supported. 
 
We looked at this coder's review, the file, and Medicare rules. 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 81345 billed for March 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) provided on January 23, 
2023. 
 
You asked the Plan to pay for drug testing. You say that this test was medically necessary and was ordered by 
the enrollee's physician. The Plan denied your request. The Plan says there is insufficient information to 
support the medical necessity of the drug testing billed. 
 
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. 
 
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 drug testing have been met. 
Specifically, there is no information in the order report to clarify which drugs were requested for testing in this 
case. Without evidence that the enrollee's treating physician specifically requested for all drugs tested to be 
tested, we cannot verify the medical necessity of the number of drug classes tested in this case. Therefore, we 
decided that the Plan does not have to pay for definitive drug testing (G0483) provided on January 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown - porcelain fused to high noble metal (D2750) for 
tooth number 29 provided on March 11, 2021. 
 
You asked the Plan to pay for a crown - porcelain fused to high noble metal (D2750) for tooth number 29. You 
say that you did not know that you have dental benefits. You also say that the providers office gave you 
incorrect ledgers on a number of occasions. The Plan denied your request. The Plan says this service is not 
covered under the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a crown - 
porcelain fused to high noble metal (D2750) for tooth number 29 provided on March 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown, porcelain fused to noble metal on 
tooth #20 (D6752). 
 
You asked the Plan to pre-approve a retainer crown. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the enrollee's benefit for the requested item 
or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the enrollee's benefit for the requested item or service was exhausted on the authorization request. 
Therefore, we decided that the Plan does not have to pre-approve a retainer crown, porcelain fused to noble 
metal on tooth #20 (D6752).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service January 30, 
2023. 
 
You asked the Plan to pay for procedure code 99214. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says payment for code 99214 is 
bundled into payment for code G0439. 
 
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 99214 
is a column II code to column I code G0439. 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 99214 billed for date of service January 30, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit system (K0108). 
 
You asked the Plan to pre-approve a transit system. You say that the requested item is necessary. The Plan 
denied your request. The Plan says equipment that is for use outside of the home or is not primarily medical in 
nature is not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a transit system (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87491 and 87798 provided on April 6, 
2023. 
 
You asked the Plan to pay for codes 87491 and 87798. You say that these services were billed correctly. The 
Plan denied your request. The Plan says the billed codes are 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 87491 is infectious agent detection by nucleic acid 
(deoxyribonucleic acid (DNA) or ribonucleic acid (RNA)); Chlamydia trachomatis, amplified probe technique. 
The definition of 87798 is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; 
amplified probe technique, each organism. 
 
We find that CPT code 87491 and 87798 is not supported in the medical record. Specifically, the submitted 
records do not document testing for Chlamydia trachomatis to support code 87491. There is also no 
documentation of what tests are being billed with the unspecified code 87798. Based on this information, we 
decided that Medicare rules for coverage of codes 87491 and 87798 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87491 and 87798 provided on April 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87641, 87653 and 87798 billed for 
date of service February 14, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87641, 87653 and 87798. You say that these services 
were necessary and are supported in the medical record. The Plan denied your request. The Plan says these 
services are not supported for separate payment. 
 
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 codes 87481, 87641, 87653 and 87798 are column II codes to column I 
code 87801; however, 87481, 87641, 87653 and 87798 were each billed with a modifier.  
 
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 procedure codes 87481, 87641, 87653 and 87798. Our 
reviewer says that these codes are not supported for separate payment. Our reviewer found although these 
codes were reported with modifier XU, the laboratory report does not include documentation to support these 
procedure codes as unusual non-overlapping services, and therefore 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 procedure codes 87481, 87641, 87653 and 87798 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87481, 87641, 87653 and 87798 billed for 
date of service February 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (U0005, 87502, 87503, 87486, 87541, 
87581, 87651 and 87798) provided on April 25, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the laboratory panel have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the laboratory panel (U0005, 87502, 87503, 87486, 87541, 87581, 87651 and 87798) provided on April 25, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of desensitizing resin for cervical and/or root 
surface, per tooth (D9911) provided on April 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you chose this dental office because it was on 
the Plan's approved list and it was authorized before you went. The Plan denied your request. The Plan says 
there's no coverage for application of desensitizing resin for cervical and/or root surface. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
application of desensitizing resin for cervical and/or root surface, per tooth (D9911) provided on April 18, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) additional teeth extractions (D7140). 
 
You asked the Plan to pre-approve the dental services. You say that you need to have the extractions done and 
cannot afford to pay for them yourself. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 1, 2023. 
Therefore, we decided that the Plan does not have to pre-approve eight (8) additional teeth extractions (D7140).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure codes 80053, 82607, 82728, 82746, 83540, 84443, 85025, and 85046 for date of service October 24, 2022.

You asked the Plan to pay for procedure codes 80053, 82607, 82728, 82746, 83540, 84443, 85025, and 85046. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are not separately payable.

The Plan must follow Medicare rules. Medicare rules say that payment for services provided to enrollees in a Medicare covered SNF stay are included in a bundled prospective payment made through the Part A Medicare
Administrative Contractor (MAC) to the SNF.

We looked at the file and Medicare rules. Review of the file shows that the enrollee was in a covered skilled nursing facility stay for this date of service. The services at issue are included in payment to the skilled nursing facility. No separate payment can be made as billed. Based on this information, we decided that Medicare rules for coverage of procedure codes 80053, 82607, 82728, 82746, 83540, 84443, 85025, and 85046 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 80053, 82607, 82728, 82746, 83540, 84443, 85025, and 85046 for date of service October 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 13, 2023, billed 
with codes 81227, 81231, 81232, 81306, 81328 and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. 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 
February 13, 2023, billed with codes 81227, 81231, 81232, 81306, 81328 and 81335.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 21, 2023, billed 
with codes 81345, 81209, 81223, 81250, 81305 and 81320. 
 
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 
February 21, 2023, billed with codes 81345, 81209, 81223, 81250, 81305 and 81320.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trinity Elite allograft for spine surgery. 
 
You asked the Plan to pre-approve Trinity Elite allograft. You say that this is needed due to the enrollee's 
extreme pain, weakness, and functional decline. The Plan denied your request. The Plan says the clinical value 
and effectiveness of the Trinity Elite allograft in the setting of spinal fusion surgery have not been 
demonstrated. 
 
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 Trinity Elite allograft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term, peer-reviewed literature that shows 
this allograft to be a safe and effective treatment for the enrollee's 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 Trinity Elite allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Trinity Elite allograft for spine surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ViviGen allograft (20930). 
 
You asked the Plan to pre-approve a ViviGen allograft. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the ViviGen Allograft in the setting 
of anterior cervical spine fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 a ViviGen allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found ViviGen allograft remains experimental in spine surgery. More research is needed. 
 
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 ViviGen allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a ViviGen allograft (20930).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental when used as bone graft material in 
spine surgery. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upgraded electronics (E2311, E2313, E2377).  
 
You asked the Plan to pre-approve the upgraded electronics. You say that the enrollee requires a seat elevator 
to increase independence with activities of daily living (ADL) reach tasks. You also say that this is medically 
necessary for the enrollee.  The Plan denied your request. The Plan says the notes do not show a medical need 
to control the power options through the joystick. 
 
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 upgraded electronics. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has C7 quadriplegia. He is able to toilet, feed himself and use a shower wand to 
bathe independently. The enrollee has sufficient strength and function in upper extremities to manage standard 
power drives. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve upgraded electronics (E2311, E2313, E2377).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87491 billed for date of service March 24, 
2023. 
 
You asked the Plan to pay for procedure code 87491. You say that this panel was coded appropriately and 
should be paid. The Plan denied your request. The Plan says this code does not meet requirements for approval. 
 
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 87491 is infectious agent detection by nucleic acid (DNA 
or RNA); Chlamydia trachomatis, amplified probe technique. 

We find that CPT code 87491 is not supported in the medical record. Specifically, the limited records do not 
list testing for Chlamydia trachomatis as a requested service on the order form, and no result is provided for 
this test to support that it was provided as reported. It cannot be verified that this test was performed, requested 
or medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure 
code 87491 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
87491 billed for date of service March 24, 2023.