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

 
We decided that the Plan does not have to pay for procedure codes 87481, 87641, 87798, and 87640 billed for 
date of service January 10, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87641, 87798, and 87640. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says payment for codes 87481, 87641, 87798, 
and 87640 cannot be made 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. In this case, we have confirmed that code 87481 
is a column II code to column I code 87801. We have confirmed that code 87641 is a column II code to column 
I code 87801. We have confirmed that code 87798 is a column II code to column I code 87801. We have 
confirmed that code 87640 is a column II code to column I code 87641. While these codes were billed with 
modifier -59, the medical records provided do not show that the services billed with the -59 modifier are a 
distinct procedural service. 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 87481, 87641, 87798, and 87640 
billed for date of service January 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798 rendered on 
February 21, 2023.  
 
You asked the Plan to pay for the services. You say that this should be paid for.  The Plan denied your request. 
The Plan says the 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 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. The definition of code 87653 is infectious agent 
detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique and the definition 
of code 87798 is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified 
probe technique, each organism. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer found for code 87481, the 
documentation submitted was reviewed and does not meet criteria. The provider reported procedure code with 
appended modifier XU Unusual non-overlapping service; however, the laboratory report does not include 
documentation to support the separately billed procedure code and modifier. Therefore, this procedure would 
be included in code 87801, which includes infectious agent detection, multiple organisms, amplified probe 
technique. 
 
For code 87653, the documentation submitted was reviewed and does not meet criteria. The provider reported 
procedure code with appended modifier XU Unusual non-overlapping service; however, the laboratory report 
does not include documentation to support the separately billed procedure code and modifier. Therefore, this 
procedure would be included in code 87801, which includes infectious agent detection, multiple organisms, 
amplified probe technique. 
 
For code 87798, the documentation submitted was reviewed and does not meet criteria. The provider reported 
procedure code with appended modifier XU Unusual non-overlapping service; however, laboratory report does 
not include documentation to support the separately billed procedure code and modifier. Therefore, this 
procedure would be included in code 87801, which includes infectious agent detection, multiple organisms, 
amplified probe technique. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 87481, 87653, and 87798 rendered on February 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
when three or more power seating functions/actuators/motors are provided, one unit of E2311, one unit of 
E2377, and one unit of E2313 are allowed. The Plan denied your request. The Plan says although there are 
three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical 
need to control these 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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found 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, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), expandable controller (E2377).
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 the durable medical equipment (DME). You say that this is medically 
necessary.  The Plan denied your request. The Plan says although there are three approved power options on 
this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options 
through the joystick.  
 
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 durable medical equipment (DME). 
Our physician reviewer found the requested electrical accessories are not medically necessary as the member 
does have use of the upper extremity and can operate and control the power options using the switches that are 
included in the basic wheelchair. There is not a medical need for the upgraded electronics. 
 
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 durable medical equipment (DME) 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 33508 billed for date of service January 10, 
2023. 
 
You asked the Plan to pay for procedure code 33508. You say that you have submitted supporting 
documentation for reconsideration of the denied code. The Plan denied your request. The Plan says payment 
for code 33508 is bundled into payment for code 33533. 
 
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 33508 
is a column II code to column I code 33533. 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 33508 billed for date of service January 10, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit. 
 
You asked the Plan to pre-approve an office visit. You say that you do not understand why the insurance will 
not approve the requested provider who has made it clear that he is able to do the cataract surgery as a routine surgery with no laser. The Plan denied your request. The Plan says the records do not show the medical necessity for this 
level of specialty care. 
 
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 office visit. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have been approved to have an office visit with an in-network Ophthalmologist. 
 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 office visit. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an office visit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311). 
 
You asked the Plan to pre-approve an electronic connection. You say that you need a fast appeal because the 
enrollee needs their chair. The Plan denied your request. The Plan says given the lack of medical purpose 
provided by the electronic connection, the E2311 code is appropriately upheld. 
 
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. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has sufficient strength and function in their 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 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing for chemiluminescence (82397) and 
immunofluorescence (83346) billed for date of service February 16, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied.  

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 6, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for laboratory testing have not been met. Therefore, we 
decided that the Plan does not have to pay for testing for chemiluminescence (82397) and immunofluorescence 
(83346) billed for date of service February 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 16, 2023, to 
March 17, 2023, at an out-of-network (OON) facility.  
 
You asked the Plan to pay for the OON inpatient hospital services. You say that the medical records provided 
support that the inpatient hospital services were medically necessary.  The Plan denied your request. The Plan 
says after stabilization of the enrollee's clinical condition in the emergency department, they should have been 
given the opportunity to transfer the enrollee to a network facility, involve contracted providers in the care, 
and/or provide utilization management oversight. The Plan says that the records indicate that the enrollee was 
stabilized and not in any immediate danger at the time of inpatient admission.  
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the OON inpatient hospital services. Our 
reviewer says that the criteria for coverage have not been met.  Our physician reviewer found the enrollee was 
stable and appropriate for ambulance transfer with monitoring to a Plan facility for continued 
observation/admission level of care services. Post-stabilization care services on March 16, 2023, to March 17, 
2023, at the OON facility were not medically necessary or reasonable. The treating physician did not document 
(in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of 
service. 
 
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 OON inpatient hospital services have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital services provided on March 16, 2023, to March 17, 
2023, at an out-of-network (OON) facility.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Kyphoplasty.  
 
You asked the Plan to pre-approve a Kyphoplasty. You say that the requested Kyphoplasty is medically 
necessary. The Plan denied your request. The Plan says per the clinical documentation, the enrollee has a 
history of multilevel disc disease in the lower spine. Medical necessity coverage criteria is not met as the pain 
is multifactorial with multilevel disc disease in the lumbar spine. 
 
The Plan follows Medicare rules. 
 
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 Kyphoplasty. Our reviewer says that 
the requested Kyphoplasty is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee was being treated for other disorders of continuity of bone. The enrollee 
presented with lower back pain. Per the x-rays, the enrollee has an L4 compression fracture (from a fall on 
some bleachers) and the pain is constant. The problem has been gradually improving since the onset and is 
aching and burning. The pain is moderate and rated at 7/10. The exam reveals deep tendon reflexes are 1+ on 
the bilateral patellar and Achilles. However, detailed documentation is not evident regarding worsening pain. 
There is no indication of a progression of the body height loss, greater than 25% vertebral body height loss, 
kyphotic deformity, or a severe impact on daily activities. Moreover, there is magnetic resonance imaging 
(MRI) corroboration of other plausible causes of back pain. Therefore, the requested Kyphoplasty does not 
meet the Medicare LCD coverage criteria. 
 
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 Kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left side sacroiliac joint injection. 
 
You asked the Plan to pre-approve the injection. You say that the enrollee is currently under the physician's 
care. The Plan denied your request. The Plan says a sacroiliac joint injection 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 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 injection. Our reviewer says that the 
enrollee does not meet the LCD coverage criteria. Our physician reviewer found that there are no positive 
physical exam findings on the left. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a left side sacroiliac joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 9, 
2022. 
  
You asked the Plan to pay for procedure code 99100. You say that the documents should be reviewed for 
appeal resolution. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty at L1 (22514). 
 
You asked the Plan to pre-approve a kyphoplasty. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a kyphoplasty is covered when the criteria listed in 
the Medicare rules section 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 a kyphoplasty. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that the detailed documentation is not 
evident regarding a compression fracture at the L1 level. There is no indication of any acute/subacute 
compression fractures. 
 
 
 
 
 
 
 
 
 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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty at L1 (22514).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae BRCA1/2 (breast cancer 1 and 2) Panel (81433) 
 
You asked the Plan to pay for the laboratory service. 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 the request for BRCA1/2 (81433) tests for genes already included in the Invitae Multi-Cancer Panel 
(81432) 
 
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 find that the request for BRCA1/2 (81433) tests for genes already included in the Invitae Multi-
Cancer Panel (81432) and is duplicative, not expected to give additional information separate from the 
approved test and is unnecessary. The Invitae BRCA1/2 Panel (81433) is also non-covered by Medicare per 
DEX Diagnostics Exchange. Based on this information, we decided that Medicare rules for coverage of the 
laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for the Invitae 
BRCA1/2 (breast cancer 1 and 2) Panel (81433)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cup holder (K0108). 
 
You asked the Plan to pre-approve a cup holder. You say that you are requesting a formal review and a split 
decision rendered as deemed appropriate. The Plan denied your request. The Plan says a cup holder does not 
serve a medical purpose and is not considered durable medical equipment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a cup holder (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4342) for the 
lower right quadrant. 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service. 
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 Plans 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 Plan paid for the periodontal scaling and root planing (D4341) for the lower right quadrant on 
January 5, 2022; therefore, your benefit for the requested item or service was exhausted on the date of service 
of January 5, 2022. Therefore, we decided that the Plan does not have to pre-approve the periodontal scaling 
and root planing (D4342) for the lower right quadrant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT imaging. 
 
You asked the Plan to pay for cone beam CT. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 cone 
beam CT imaging.