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

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); Chlamydia trachomatis, amplified probe technique (87491) infectious agent detection by nucleic acid 
(DNA or RNA); Neisseria gonorrhoeae, amplified probe technique (87591) provided April 13, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that kindly reconsider this claim for payment of 
services rendered. The Plan denied your request. The Plan says based on Medicare guidelines, the ArkStone 
urinary tract infection panel requested does not meet the requirements for approval. 
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that under Medicare guidelines, the request is not medically 
necessary because the medical records show the test is not FDA or MolDX approved. The review has 
determined that the items/services at issue in this case were 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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, 
amplified probe technique (87491) infectious agent detection by nucleic acid (DNA or RNA); Neisseria 
gonorrhoeae, amplified probe technique (87591) provided April 13, 2023.
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 May 11, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that the surgeon/facility was in-network, so this 
service should be authorized. 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 May 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sales taxes for compression garments provided from March 
29, 2023, to April 7, 2023. 
 
You asked the Plan to pay for sales taxes. You say that the wrong codes were used for this. The Plan denied 
your request. The Plan says sales taxes are not separately paid by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that sales taxes are included in the calculation of the 
Medicare fee schedule so are not separately paid.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of sales taxes have not been met. Therefore, we decided that the Plan does not have to pay for sales 
taxes for compression garments provided from March 29, 2023, to April 7, 2023.
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 November 
10, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the Plan denied this claim incorrectly based 
on a provider registry issue. 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 November 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345-GZ provided on July 26, 2022. 
 
You asked the Plan to pay for procedure code 81345-GZ. 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 state that items submitted with a GZ modifier shall be 
denied automatically and will not be subject to complex medical review. 
 
We find that CPT code 81345 is not supported in the medical record. Specifically, this service includes the GZ 
modifier, which by definition means that this service does not meet the criteria for Medicare coverage. Based 
on this information, we decided that Medicare rules for coverage of the services described by procedure code(s) 
81345-GZ have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
81345-GZ provided on July 26, 2022.
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 January 3, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that the Plan denied this claim incorrectly based 
on a provider registry issue. 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 January 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313), an expandable controller (E2377), a 
toggle kit (K0108) and a color 3.5 touch screen remote/joystick (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested wheelchair and all 
requested accessories are medically necessary for the enrollee. The Plan denied your request. The Plan says 
Medicare guidelines says that upgraded electronics are 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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided, there is no documentation that the requested 
accessories at issue in this case meet all Medicare criteria for medically reasonable and necessary for the 
enrollee. Provided records document that the enrollee is able to complete the activities of eating, oral hygiene 
and upper body dressing with set-up/clean-up assistance thus indicating she has adequate upper extremity 
strength and function to operate the wheelchair's power options with their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313), an expandable controller (E2377), a toggle kit (K0108) and 
a color 3.5 touch screen remote/joystick (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic - porcelain/ceramic (D6245) for tooth number 
13. 
 
You asked the Plan to pre-approve a pontic - porcelain/ceramic (D6245) for tooth number 13. You say that it is 
necessary for the pontic procedure to be completed after the tooth is extracted. The Plan denied your request. 
The Plan says this is denied because tooth number 13 is still present and cannot be replaced with a pontic.  
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. The Plan covers a pontic - 
porcelain/ceramic (D6245) for tooth number 13 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 a pontic - porcelain/ceramic (D6245) 
for tooth number 13. Our reviewer says that the service is not medically necessary. Our physician reviewer 
found that a pontic for number 13 as requested is not needed. Our physician reviewer also found that tooth 
number 13 is present. 
 
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 a pontic - porcelain/ceramic (D6245) for tooth number 13 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a pontic - porcelain/ceramic (D6245) for 
tooth number 13.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued use of a home ventilator for nine months. 
 
You asked the Plan to pre-approve the continued use of a home ventilator for nine months. You say that the 
enrollee continues the need for a ventilator. The Plan denied your request. The Plan says a home ventilator is 
not medically necessary for this patient because their needs can be met with an alternative device such as a 
BiPAP device with average volume-assured pressure support (AVAPS). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 continued use of a home ventilator 
for nine months. Our reviewer says that the service is not medically necessary. Our physician reviewer found 
this enrollee has very severe COPD. A home ventilator was prescribed in 2020 following a hospitalization, 
during which an arterial blood gas was consistent with acute on chronic hypercarbic respiratory failure. The 
medical record does not show evidence that the enrollee has been tried on BiPAP with AVAPS during sleep as 
an outpatient. Medicare does not cover a home ventilator when used at settings that can be provided with 
BiPAP. The plan has approved the ventilator for 3 months, which allows time for transition to BiPAP. 
 
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 continued use of a home ventilator for nine months have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the continued use of a home ventilator for 
nine months.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 28, 2023, billed 
with codes 81226, 81240, 81241, and 81328. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 28, 2023, billed with codes 81226, 81240, 81241, and 81328.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 8, 2023.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 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. The rules also say that the physician must clearly document, in the medical record, his or her intent that the test be performed.

We find that the billed lab services are not supported in the medical record. Specifically, the records provided do not contain an order for the specific tests provided in this case. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D7286 and D9610) on August 5, 2022.  
 
You asked the Plan to pay for the dental services (D7286 and D9610). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the dental services (D7286 and 
D9610) are not covered benefits. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services (D7286 and D9610) on August 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36200 and 75710 performed on May 16, 
2023. 
 
You asked the Plan to pay for 36200 and 75710. You say that 36200 and 75710 are supported in the 
documentation. The Plan denied your request. The Plan says 36200 and 75710 are not eligible for separate 
payment because they are included in code 37228. The modifier used for both, XU (unusual non-overlapping 
service), is not supported because records do not show these services were independent of other services 
performed on the same day. 
 
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 36200 and 75710 are column II codes to column I code 37228; 
however, 36200 and 75710 were both billed with a modifier.  
 
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 36200 and 75710. Our reviewer says that 
36200 and 75710 are not supported. Although they were billed with modifier XU, our reviewer found the 
documentation does not support that 36200 and 75710 were non-overlapping services, so they do not meet 
criteria to bypass the NCCI edit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 36200 and 75710 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 36200 and 75710 performed on May 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0230) on April 7, 2023. 
 
You asked the Plan to pay for the dental service (D0230). You say that you would like to request 
reconsideration of the denied claim and that the services requested are 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 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 on date of service April 7, 2023. Therefore, 
we decided that the Plan does not have to pay for the dental services (D0230) on April 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80307, G0480, and 83789 provided on June 
9, 2023. 
 
You asked the Plan to pay for procedure codes 80307, G0480, and 83789. 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 
supported 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, the CPT Code Manual definition of code 80307 is Drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay 
[eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry 
either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, 
MALDI, TOF) includes sample validation when performed, per date of service.  
 
The definition of code G0480 is Drug test(s), definitive, utilizing (1) drug identification methods able to 
identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), 
including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and 
excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), 
(2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix 
effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-
matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative 
or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including 
metabolite(s) if performed. 
 
We find that CPT codes 80307 and G0480 are not supported in the medical record. Specifically, the 
documentation provided for review did not include a lab order to verify that the testing performed matched the 
testing requested.  
 
Medicare rules also say that providers performing validity testing on urine specimens utilized for drug testing 
should not separately bill the validity testing. We find that the testing described by 83789 is not separately 
payable. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 80307, G0480, and 
83789 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 80307, 
G0480, and 83789 provided on June 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office for home 
use (D9630), periodontal maintenance (D4910), topical application of fluoride varnish (D1206), and tele 
dentistry - synchronous; real-time encounter (D9995) provided on April 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that the submitted claims should be only for the 
dental services covered under your plan and for the dollar amounts allowed. The Plan denied your request. The 
Plan says these services are not a covered expense under your dental 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. 
 
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 the drugs 
or medicaments dispensed in the office for home use (D9630), periodontal maintenance (D4910), topical 
application of fluoride varnish (D1206), and tele dentistry - synchronous; real-time encounter (D9995) 
provided on April 28, 2023.  
 
Your complaint about the dental provider is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve manual therapy (97140) and therapeutic activities 
(97530). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.  
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pre-approve manual therapy (97140) and therapeutic activities (97530).