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

 
We decided that the Plan does not have to pay for hereditary gene analysis (81321) provided on October 6, 
2022. 
 
You asked the Plan to pay for hereditary genetic testing. You say that this testing was medically necessary and 
was ordered by the enrollee's physician. The Plan denied your request. The Plan says this test as provided as 
part of a screening which is not covered by Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, hereditary genetic testing, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for hereditary gene analysis (81321) provided on October 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits (99204, 99205, 99213, 99214) with an oncologist to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve office visits. You say that you had a biopsy, and you have spots on your lungs. You need to start treatment. You have an upcoming appointment with the requested provider on June 28, 2023.You can have it sooner if approved. The Plan denied your request. The Plan says you must receive your care from a network provider. The Plan has network oncologists as well as tertiary providers that can provide the services at issue in this request.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office visits (99204, 99205, 99213, 99214) with an oncologist to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the dental service. You say that you are in pain and the requested partial is 
medically necessary. 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 the date of service of December 28, 
2021. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 87086 and 87186) 
rendered on October 28, 2022. 
 
You asked the Plan to pay for the services. You say that you are appealing this claim with medical records to 
show medical necessity for why this service was performed. The Plan denied your request. The Plan says he 
documentation does not support that the services was completed 
 
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 the denied codes is: 
 
Current Procedural Terminology (CPT) 87186: Susceptibility studies, antimicrobial agent; microdilution or 
agar dilution (minimum inhibitory concentration [MIC] or breakpoint), each multi-antimicrobial, per plate 
 
Current Procedural Terminology (CPT) 87086: Culture, bacterial; quantitiative colony count, urine 
 
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 says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the laboratory report does not 
include documentation of either code in the records. 
 
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 laboratory services (procedure code 87086 and 87186) rendered on October 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant (D6010), second stage 
implant surgery (D6011), custom fabricated abutment (D6057) and a crown (D6058) for teeth #5 and #13. 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you have already been approved for 2 implants for teeth #21 and #23. 
 
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 your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does not have to pre-approve surgical placement of implant (D6010), second stage implant surgery (D6011), custom 
fabricated abutment (D6057) and a crown (D6058) for teeth #5 and #13.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint peripheral nerve stimulator (PNS) system 
(64555, C1778). 
 
You asked the Plan to pre-approve a Sprint PNS system. You say that the requested treatment is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that electro-acupuncture devices used for stimulation 
of auricular acupuncture points are non-covered. Based on this information, we decided that Medicare rules for 
coverage of a Sprint PNS system have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Sprint peripheral nerve stimulator (PNS) system (64555, C1778).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87900 provided on October 24, 2022. 
 
You asked the Plan to pay for procedure code 87900. You say that the medical records support the billing of 
code 87900.  The Plan denied your request. The Plan says the medical records do not support the billing of 
code 87900.  
 
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 87900 is Infectious agent drug susceptibility phenotype 
prediction using regularly updated genotypic bioinformatics.  

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 code 87900. Our reviewer says that the medical 
records do not support the billing of code 87900.  Our reviewer found the medical records provided do not 
include sufficient documentation to validate that 87900-Infectious agent drug susceptibility phenotype 
prediction using regularly updated genotypic bioinformatics was performed on October 24, 2022, therefore, 
this procedure 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 code 87900 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87900 provided on October 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extraspinal chiropractic manipulation described by code 
98943. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Extraspinal manipulation is 
not covered when performed by a chiropractor. Therefore, we decided that the Plan does not have to pre-
approve extraspinal chiropractic manipulation described by code 98943.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87631 and 99072 provided on July 26, 
2022. 
 
You asked the Plan to pay for procedure codes 87631 and 99072. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. Additionally, procedure code 99072 is 
considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported.  
 
Medicare rules also say that providers must report services correctly. Providers must report services with the 
appropriate procedure code. We find that procedure code 99072 has a status indicator of B on the Physician Fee 
Schedule. This means that procedure code 99072 is not separately payable.  
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 87631 and 99072 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87631 and 
99072 provided on July 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requirements 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that there is no trial of bracing. More conservative measures are 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment (DME) repair of a shroud 
cover. 
 
You asked the Plan to pre-approve a shroud cover. You say that the enrollee's current power wheelchair has 
had $3,712 in repairs thus far. You say that the requested repair would total $818. You say that a new power 
wheelchair would cost $22,000 to $24,000. You also say that the requested repairs should be allowed. The Plan 
denied your request. The Plan says a shroud cover does not service a primarily medical purpose.  

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 durable medical equipment (DME) repair of a shroud cover.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four (4) office visits (99205, 99215, 99241, 99242, 
99243, 99441, 99442, 99443) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve office visits. You say that your condition has worsened, and you need to see 
this provider. The Plan denied your request. The Plan says you must use network providers to get your medical 
care and services. Services are available from in-network providers within a reasonable distance from your 
home. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
four (4) office visits (99205, 99215, 99241, 99242, 99243, 99441, 99442, 99443) to be provided by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on December 5, 2022.

You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing.

The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not separately payable. Laboratories should bill the facility directly for laboratory services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on December 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 84480 billed for date of service July 6, 2022.  
 
You asked the Plan to pay for procedure code 84480. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 84480 is bundled into 
payment for code 84481. 
 
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 84480 
is a column II code to column I code 84481 with a modifier indicator of 0. The column II 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 84480 billed for date of service July 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interim implant abutment placement (D6051), custom 
fabricated abutment - includes placement (D6057), implant supported crown - porcelain fused to high noble 
alloys (D6066) and interim implant crown (D6085). 
 
You asked the Plan to pre-approve dental services. You say that you do not agree with the crown being denied. 
The Plan denied your request. The Plan says these services are not covered under your 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. Interim implant abutment 
placement (D6051), custom fabricated abutment - includes placement (D6057), implant supported crown - 
porcelain fused to high noble alloys (D6066) and interim implant crown (D6085) are not covered under the 
Plan's dental benefits. 
 
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 pre-approve 
interim implant abutment placement (D6051), custom fabricated abutment - includes placement (D6057), 
implant supported crown - porcelain fused to high noble alloys (D6066) and interim implant crown (D6085).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11042 billed for date of service August 10, 
2022.  
 
You asked the Plan to pay for procedure code 11042. You say that medical records were provided. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 11042 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 11042 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 11042 billed for date of service August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift feature. 
 
You asked the Plan to pre-approve a seat lift feature. You say that the power recline option is medically 
necessary for spasticity control and management. You also say that it provides optimal pressure relief and postural support. The Plan denied your request. The Plan says the seat lift feature does not serve a primary 
medical purpose and is statutorily non-covered. 
 
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 seat lift feature.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87900 provided on January 4, 2023. 
 
You asked the Plan to pay for procedure code 87900. You say that the medical records support the billing of 
code 87900.  The Plan denied your request. The Plan says the medical records do not support the billing of 
code 87900.  
 
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 87900 is Infectious agent drug susceptibility phenotype 
prediction using regularly updated genotypic bioinformatics.  
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 code 87900. Our reviewer says that the medical 
records do not support the billing of code 87900.  Our reviewer found per medical records attached, no 
quantitative infectious agent drug susceptibility was completed. 
 
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 code 87900 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87900 provided on January 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64420, 64421 billed for date of service June 
2, 2022.  
 
You asked the Plan to pay for procedure code 64420, 64421. You say that you disagree with the denial and 
request reconsideration for payment on this claim. The Plan denied your request. The Plan says payment for 
code 64420, 64421 is bundled into payment for code 21555. 
 
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 64420, 
64421 is a column II code to column I code 21555 with a modifier indicator of 0. The column II 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 64420, 64421 billed for date of service June 
2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous vertebral augmentation, including 
cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar 
(22514). 
 
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 this enrollee does not meet criteria in the absence of conservative therapy, 
the lack of severe/debilitating pain, and evidence of severe impact on daily functioning. 
 
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 physician reviewer 
found detailed documentation is not evident that the compression fracture is acute or subacute. The x-rays from 
May 12, 2023, indicate the compression fracture at L3 is chronic. Additionally, the exam does not corroborate 
any worsening pain or that the pathology has a severe impact on daily functioning. Therefore, the medical 
records provided do not meet the requirements listed in the LCD for Medicare coverage. 
 
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 percutaneous vertebral augmentation, including cavity creation (fracture reduction and 
bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral 
or bilateral cannulation, inclusive of all imaging guidance; lumbar (22514).