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

 
We decided that the Plan does not have to pay for infectious-agent testing (87506) billed for date of service 
October 4, 2022. 
 
You asked the Plan to pay for infectious-agent testing. You say that the service at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of infectious-agent testing have been met. 
Specifically, there is insufficient information in the record to determine whether the reported date of service 
October 4, 2022, is correct. Therefore, we decided that the Plan does not have to pay for infectious-agent 
testing (87506) billed for date of service October 4, 2022.