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

 
We decided that the Plan does not have to pay for laboratory testing services (87491, 87529, 87591, 87625, 
87640 and 87661) billed for date of service March 6, 2023. 
 
You asked the Plan to pay for procedure codes 87491, 87529, 87591, 87625, 87640 and 87661. You say that 
you have billed the services at issue correctly. The Plan denied your request. The Plan says the provided 
records do not support 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 87491 is: Infectious agent detection by nucleic acid 
(DNA or RNA); Chlamydia trachomatis, amplified probe technique. 
 
The definition of code 87529 is: Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex 
virus, amplified probe technique. 
 
The definition of code 87591 is: Infectious agent detection by nucleic acid (DNA or RNA); Neisseria 
gonorrhoeae, amplified probe technique. 
 
The definition of code 87625 is: Infectious agent detection by nucleic acid (DNA or RNA); Human 
Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed. 
 
The definition of code 87661 is: Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas 
vaginalis, amplified probe technique. 
 
In this case, we have confirmed that code 87640 is a column II code to column I code 87641; however, 87640 
was 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 87491, 87529, 87591, 87625, 87640 and 
87661. Our reviewer says that procedure codes 87491, 87529, 87591, 87625, 87640 and 87661 do not meet 
criteria for payment. Our reviewer found that code 87640 with a 59 modifier is not supported as this code is 
included with code 87641. Codes 87491, 87529, 87591, 87625 and 87661 are not supported as the sample was 
a clean-catch urine sample. 
 
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 87491, 87529, 87591, 87625, 87640 and 87661 have not been 
met. Therefore, we decided that the Plan does not have to pay for laboratory testing services (87491, 87529, 
87591, 87625, 87640 and 87661) billed for date of service March 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
March 15, 2023, to March 16, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you disagree with the 
copayment. 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 $140 
copayment for inpatient hospital care. 
 
You have been asked to pay a $140 copayment for the inpatient hospital stay. This item/service falls within the 
inpatient hospital 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. You have been asked to pay a total of $140 for the inpatient hospital stay ($140 copayment 
x 1 day = $140). You have not been charged for the day you were discharged. Therefore, we decided that the 
Plan does not have to waive the copayment for the inpatient hospital stay provided on March 15, 2023, to 
March 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Providence Medical DTRAX instrument (22840). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of Providence Medical DTRAX in the 
setting of cervical stenosis and radiculopathy, 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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested DTRAX is noted to be requested in associated revision procedures as adjuvant implants to treat pseudarthrosis or atlantoaxial instability. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting for review. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested Providence Medical DTRAX instrument 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Providence Medical DTRAX instrument (22840).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Kerecis Omega3 MariGen Shield, per sq cm. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the records do not show a skin defect that has persisted despite optimal wound care 
for more than four weeks. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the records show documentation of a wound with failed response to appropriate wound care measures. 
The records show evidence of failed first line therapies 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve Kerecis Omega3 MariGen Shield, per sq cm.  
 
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 pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection (E2311), harness (E2313), and expandable 
controller (E2377). You say that the requested electronic connection (E2311), harness (E2313), and expandable 
controller (E2377) are medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for the requested electronic connection (E2311), harness (E2313), and expandable controller 
(E2377). 
 
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 an electronic connection (E2311), 
harness (E2313), and expandable controller (E2377). Our reviewer says that the enrollee does not meet criteria 
for the requested electronic connection (E2311), harness (E2313), and expandable controller (E2377). Our 
physician reviewer found the enrollee has paraplegia. She has 3/5 strength in her upper extremities. The 
physician does not identify contractures bilaterally in hands and wrists. 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 an electronic connection (E2311), harness (E2313), and expandable controller 
(E2377) have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic 
connection (E2311), harness (E2313), and expandable controller (E2377).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health skilled nursing (G0299 x15).  

You asked the Plan to pre-approve home health services. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation does not specify any new wound concerns or change in plan of care (wraps are being applied 
but does not provide rational for ongoing skilled service), new/acute medical concerns, changes in medications 
thus the records do not show that 15 home health skilled nursing visits are required to effectively provide 
treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the home health skilled nursing (G0299 x15).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84436 and 84479 billed for date of service 
April 4, 2023.   

You asked the Plan to pay for procedure codes 84436 and 84479. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for codes 84436 and 
84479 are bundled into payment for code 84439. 
 
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 84436 and 84479 are column two codes to column one code 84439 with a modifier indicator of 0. The column two codes are 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 codes 84436 and 84479 billed for date 
of service April 4, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve revision L3-S1 fusion with instrumentation with revision of the S1 
screws bilaterally and possible placement of screws into the pelvis with addition of more bone graft (22633, 
22634, 22842, 22853, 63052, and 63053). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the services are not medically necessary because the records show the 
enrollee did not have relief of pain symptoms following the previous spine surgery. 
 
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 services. Our physician reviewer 
found this enrollee has a documented nonunion with computed tomography (CT) evidence of lucency. The 
enrollee did not improve with the original surgery, but the original surgery never healed. Revision surgery for 
nonunion is medically appropriate and 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve revision L3-S1 fusion with instrumentation with revision of the S1 screws bilaterally and possible 
placement of screws into the pelvis with addition of more bone graft (22633, 22634, 22842, 22853, 63052, and 
63053).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 for date of service May 6, 2022. 
 
You asked the Plan to pay for procedure code 87481. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. 
 
We find that CPT code 87481 is not supported in the medical record. Specifically, five units were billed but 
only four were tested (Candida albicans, Candida glabrata, Candida lusitaniae, and Candid dublinenensis). 
Based on this information, we decided that Medicare rules for coverage of procedure code 87481 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 87481 for date of service 
May 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 testing (U0005) provided on May 9, 2023. 
 
You asked the Plan to pay for U0005. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says U0005 is an add-on code, but an appropriate primary code was not billed for this 
date of 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 U0005 is infectious agent detection by nucleic acid; 
severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [COVID-19]), amplified 
probe technique, cdc or non-cdc, making use of high throughput technologies, completed within 2 calendar 
days from date of specimen collection (list separately in addition to either hcpcs code u0003 or u0004). 
 
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 U0005. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found U0005 is an add-on code that requires U0003 or U0004 as a primary 
code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of U0005 have not been met. Therefore, we decided that the Plan does not have to 
pay for COVID-19 testing (U0005) provided on May 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 3D dental surface scan - direct (D0801). 
 
You asked the Plan to pre-approve the 3D dental surface scan. You say that this service was approved 
previously. You also say that when another tooth was taken to hold the denture it was denied. The Plan denied 
your request. The Plan says this service is not included in your dental plan coverage. 
 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 3D dental 
surface scan - direct (D0801).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an MRI and a CT scan performed on May 
4, 2023. 
 
You asked the Plan to reduce the copayment for an MRI and a CT scan. You say that you spoke to a Plan 
representative and was only advised of the $75 copayment for an MRI but feel you should have been advised of 
the additional copayments as well. 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 
copayment for a diagnostic CT scan at a freestanding provider and a $75 copayment for Medicare-covered 
MRI, MRA, and Angiogram at a freestanding provider.  
 
You have been asked to pay a $125 copayment for an MRI and a CT scan. This total includes a $50 copayment 
for a CT scan and a $75 copayment for an MRI. This item/service falls within the outpatient diagnostic tests 
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 reduce the copayment for an MRI, a CT scan, and an 
injection performed on May 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2950) provided on March 7, 2023. 
 
You asked the Plan to pay for D2950. You say that you feel like this should be covered. The Plan denied your 
request. The Plan says the denied dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a core 
build-up (D2950) provided on March 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81218, 81272, 81307, 81314, 81334, 81345, 
81351, and 81479 provided on May 15, 2023. 
 
You asked the Plan to pay for procedure codes 81218, 81272, 81307, 81314, 81334, 81345, 81351, and 81479. 
You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The 
Plan says the services are not covered 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 81218, 81272, 81307, 81314, 81334, 81345, 81351, and 81479 are not supported in the 
medical record. Specifically, a panel was performed and there is a more appropriate singular code for the 
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 codes 81218, 81272, 81307, 
81314, 81334, 81345, 81351, and 81479 provided on May 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mammogram services provided on June 16, 2023. 
 
You asked the Plan to pay for the mammogram services. You say that the services were medically necessary, 
and authorization is not required for these services. 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 mammogram 
services provided on June 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits, drug injections, and laboratory services 
provided on October 28, 2021, to December 30, 2021. 
 
You asked the Plan to pay for the office visits, drug injections, and laboratory services. You say that you want 
these charges reviewed, and do not feel you are responsible for paying them. 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 office visits, drug 
injections, and laboratory services provided on October 28, 2021, to December 30, 2021.