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

 
We decided that the Plan does not have to pay for the genetic testing billed with codes 0018U and 0245U 
provided on August 21, 2023. 
 
You asked the Plan to pay for the genetic testing billed with codes 0018U and 0245U. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 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. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
billed with codes 0018U and 0245U have not been met. Therefore, we decided that the Plan does not have to 
pay for the genetic testing billed with codes 0018U and 0245U provided on August 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing billed with codes 81162, 81201, 81292, 
81295, 81298, 81307, 81317, 81321, 81351, and 81334 for date of service July 10, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 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. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing billed with 
codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, and 81334 for date of service July 10, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81003 and 84132) provided July 17, 
2023. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 81003 is urinalysis, by dip stick or tablet reagent for 
bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy. The definition of code 84132 potassium; serum, 
plasma or whole blood. 
 
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 laboratory services. Our reviewer found for code 81003, 
it does not meet criteria for billing or reimbursement consideration. The medical records provided does not 
include results for this test (81003); therefore, there is not sufficient documentation to validate this service was 
performed on July 17, 2023.  
 
For code 84132, it does not meet criteria for billing or reimbursement consideration. The medical records 
provided does not include results for this test (84132); therefore, there is not sufficient documentation to 
validate this service was performed on July 17, 2023. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (81003 and 84132) provided July 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 22, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on August 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required for tooth 
#18 (D2950), a retainer crown on tooth #18 (D6750) and a pontic, porcelain fused to high noble metal on tooth 
#19 (D6240). 
 
You asked the Plan to pre-approve the dental services. You say that you need all of these dental services. The 
Plan denied your request. The Plan says the x-ray does not prove medical necessity for a core build up (D2950) 
on tooth #18. The Plan also says you have reached your benefit limit for a retainer crown and pontic porcelain 
fused. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found that included was an x-ray of teeth 
#18, #20, and #21. The end of the roots of these teeth were not captured on the x-ray. Teeth #18, #20, and #21 
have existing silver fillings. Tooth #19 is not present in the mouth. There is a space between teeth #18 and #20. 
There is early to moderate bone loss around the teeth. There were no clinical notes or narrative provided. Based 
on the information to review, D2950 for tooth #18 is not medically necessary, D6750 for tooth #18 is not 
medically necessary, and D6240 for tooth #19 is not medically necessary. An x-ray that shows tooth #18 and 
#20 must be included to make an adequate diagnosis. More information is needed. A dental bridge is an option 
to replace a missing tooth, but in order to diagnose a bridge, the teeth that are holding the bridge must have a 
good prognosis (determined by an x-ray and a periodontal charting record). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve core buildup, including any pins when required for tooth #18 (D2950), a retainer 
crown on tooth #18 (D6750) and a pontic, porcelain fused to high noble metal on tooth #19 (D6240).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's care can continue to be provided in the 
current inpatient hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found The enrollee had a tracheostomy and was ventilator dependent from a prior 
hemorrhagic stroke prior to hospital admission for sepsis.  LTACH for ventilator weaning seems unlikely given 
history of ventilator-dependence.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are necessary. The Plan 
denied your request. The Plan says the criteria for an LTACH admission has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the current acute care hospital. The 
enrollee does not require services at the LTACH that are not already available. The requested LTACH services 
are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and 
able to be furnished safely and effectively only on an inpatient basis. 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on August 2, 2023, billed with 
procedure codes 93005 and 93041-59. 
 
You asked the Plan to pay for the testing services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the services are considered bundled and are not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that if a claim includes a service that is assigned 
status indicator S, T, or V reported on the same claim as the STV- packaged service, the payment for the STV-
packaged service is packaged into the payment for the service(s) with status indicator S, T, V and no separate 
payment is made for the STV-packaged service.  
 
We looked at the file and Medicare rules. The billed codes have a Q1 status indicator and are not separately 
payable when billed with code 99285, which has a status indicator V. Based on this information, we decided 
that Medicare rules for coverage of the testing services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for testing services provided on August 2, 2023, billed with procedure codes 
93005 and 93041-59.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service July 20, 
2023. 
 
You asked the Plan to pay for the billed service. You say that medical records were provided for review. The 
Plan denied your request. The Plan says an appropriate primary diagnosis was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 We find that CPT code 88305 was billed with primary diagnosis code R63.4, defined as abnormal weight loss. 
The definitive diagnosis code should be sequenced before the symptom code. Based on this information, we 
decided that Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88305 billed for date of service July 20, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 additional skilled-nursing visits. 
 You asked the Plan to pre-approve skilled nursing. You say that the requested services are a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested 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 skilled nursing. Our reviewer says that 
the services are not medically reasonable and necessary. Our physician reviewer found that the enrollee is 
noted to be medically stable. The enrollee does not require wound care, catheterization, G-tube feeding or 
administration of intravenous or complex medications. The enrollee has been educated regarding their 
medications, medical conditions and fall prevention, and the enrollee has not recently been hospitalized. The 
enrollee requires supervision and stand-by assistance for mobility and transfers and for fall prevention, but 
these services does not require skilled-nursing care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skilled nursing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 9 additional skilled-nursing visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically 
necessary. The Plan denied your request. The Plan says the LTACH services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility being offered by the health Plan. Transfer to the LTACH is not 
medically necessary as it would not be clinically advantageous at this time. Completion of treatment at the 
current facility is recommended.  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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (83789-59) provided July 3, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not supported by the records.  
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 83789 is a column II code to column I code G0480; however, 83789 
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 the laboratory service. Our reviewer found the medical 
documentation does not support the use of 83789, as this encounter was a drug screening covered with G0480. 
Code 83789 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 the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory service (83789-59) provided July 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH admission. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the medical records provided show that the enrollee does not meet the LTACH 
admission 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 LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on October 04, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that the services should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit and 
related services provided on October 04, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the flow cytometry coded 88189 for date of service August 
30, 2023. 
 
You asked the Plan to pay for the flow cytometry. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for code 88189 is limited to the 
diagnosis codes listed.  
 
We looked at the file and Medicare rules. Procedure code 88189 is only covered when billed with specific 
diagnosis codes. Diagnosis J18.8 is not listed as a covered diagnosis for this service. Based on this information, 
we decided that Medicare rules for coverage of the flow cytometry have not been met. Therefore, we decided 
that the Plan does not have to pay for the flow cytometry coded 88189 for date of service August 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic Gene Panel (0345U) provided 
on September 19, 2023. 
 
You asked the Plan to pay for the GeneSight Psychotropic Gene Panel. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says the clinical records do not show that the provider has 
already considered non-genetic factors to make a preliminary drug selection. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the rules 
section of this letter 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 pay for the GeneSight Psychotropic Gene Panel. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that based on review 
the records provided the medication has not been found to be useful in assistance with the enrollees condition 
as according to the LCD this test is considered reasonable and necessary in limited circumstances once a 
treating clinician as narrow treatment possibilities to specific medications under consideration or use or is 
already using a specific medication, based on other clinical considerations including the enrollees diagnosis, 
the enrollees other medical conditions, other medications, professional judgment, clinical science and basic 
science pertaining to the drug and the enrollees preferences and values. Utilizing the information provided and 
from Medicare LCD, this enrollee does not meet the criteria for GeneSight Psychotropic Assay and is not 
considered medically necessary and reasonable in the treatment of this individual. 
 
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 GeneSight Psychotropic Gene Panel have not been met. Therefore, we 
decided that the Plan does not have to pay for the GeneSight Psychotropic Gene Panel (0345U) provided on 
September 19, 2023.