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

 
We decided that the Plan does not have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 9, 2023. 
 
You asked the Plan to pay for OIVIT services. The Plan denied your request. The Plan says the billed services 
are not supported. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 22, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on June 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
(E0601) provided on June 28, 2023. 
 
You asked the Plan to pay for the CPAP device. You say that the item was medically necessary. The Plan 
denied your request. The Plan says there is no indication as to if this item was received, needed or ordered. 
 
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. DMEPOS is covered only when there is a valid physician order, proof of 
delivery and relevant medical records which support medical necessity. 
 
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 the CPAP device have been met. The 
records does not contain a valid physician order, proof of delivery and relevant medical records which support 
medical necessity. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the continuous positive airway 
pressure (CPAP) device (E0601) provided on June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29581 billed for date of service August 4, 
2023. 
 You asked the Plan to pay for procedure code 29581. The Plan denied your request. The Plan says payment for 
code 29581 is bundled into payment for code 11043. 
 
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 29581 
is a column II code to column I code 11043. 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 29581 billed for date of 
service August 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that you do have an approved DEX-Z code for this lab 
service. 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. Although you claim that you have a DEX-Z code for the lab service billed, no such code was on 
the claim you submitted. 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 lab services provided 
on November 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 87636, G2023 and P9604 
provided March 30, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that in the case of laboratory provides, which do 
not have access to patient information, it is your position that lack of timely filing does not constitute equitable 
forfeiture. The Plan denied your request. The Plan says the claim was received after the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until April 4, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services coded as 87636, G2023 and P9604 
provided March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services coded as 99223 
billed on May 5, 2023, 99233 billed on May 8, 2023, and 99232 billed on May 9,10, and 12, 2023. 
 
You asked the Plan to pay for the evaluation and management services. You say that the evaluation and 
management services should be paid as billed because they are supported in the documentation. The Plan denied your request. The Plan says the evaluation and management services are denied because the provided 
documentation does not include the actual dates of service on which they were performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 99223, 99233, and 99232 are not supported in the medical record. Specifically, while 
the case file does contain multiple evaluation and management notes with signature dates ranging from May 5, 
2023, through May 15, 2023, only one of these notes indicates an actual date the service, which is listed as May 
4, 2023. All other evaluation and management notes included in the case file do not have documentation of the 
actual date the encounter took place. Consequently, these services cannot be verified on the billed dates. Based 
on this information, we decided that Medicare rules for coverage of the evaluation and management services 
have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation and 
management services coded as 99223 billed on May 5, 2023, 99233 billed on May 8, 2023, and 99232 billed on 
May 9,10, and 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar laminectomy with facetectomy surgery (63047). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service 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 these services. Our reviewer says that 
the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there are no electromyography (EMG) studies showing nerve root findings. The physical exam does 
not correlate with the imaging studies. The enrollee has both neck and low back symptoms. 
 
  
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar laminectomy with facetectomy surgery (63047).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown for tooth number 4 (D2740) 
and a core buildup, including any pins when required for tooth number 4 (D2950). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the 
requested dental items because tooth number 4 does not show any damage from decay or fracture that would 
require a full coverage crown and core buildup to restore. 
 
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 these dental 
items when medically necessary and reasonable.  
 
  
 
 
 
We asked our physician reviewer to carefully review the case file and apply the relevant rules to determine if 
the Plan was correct in denying the request to pre-approve these dental items. Our reviewer says that the 
requested dental items are not medically necessary. Our physician reviewer found that tooth number 4 does not 
appear to have a restoration or caries present. The narrative indicates superficial cracks in the enamel without 
symptoms. A core buildup and crown restoration does not appear to be medically necessary for tooth number 4. 
 
We looked at this physician's review, the file, and the Plans rules. Based on this information, we decided that 
the Plan's rules for coverage of these dental items have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a porcelain/ceramic crown for tooth number 4 (D2740) and a core buildup, including 
any pins when required for tooth number 4 (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) provided on March 6, 
2023. 
 
You asked the Plan to pay for the dental services. You say that if these teeth were not crowned, the enrollee 
would have eventually worn the teeth down to the pulp chamber. You also say the treatment of crowns was a 
proactive decision to save the enrollee from having to have multiple root canals. 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 annual maximum was exhausted on dates of service February 15, 2023, in the 
amount of $169, March 6, 1012, in the amount of $624, and August 31, 2023, in the amount of $207. 
Therefore, we decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) provided on 
March 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
April 17, 2023, through May 8, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says this item is not medically necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided on April 17, 2023, through May 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided to you on February 13, 2023. 
 
You asked the Plan to pay for the services. You say that you want to be reimbursed because you paid the 
provider. The Plan denied your request. The Plan says this provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
services provided to you on February 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0675 and 
half leg appliance coded E0673 billed for May 5, 2023. 
 
You asked the Plan to pay for 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. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Given that the E0675 PCD is not covered, the half leg 
appliance billed with code E0673 is also not covered. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device (PCD) coded E0675 and half leg appliance coded E0673 billed for May 
5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 16, 2023, billed with 
codes 81408, 81407, 81406, 81161, 81405 and 81404. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. 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 
May 16, 2023, billed with codes 81408, 81407, 81406, 81161, 81405 and 81404.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for provision of COVID-19 test, nonprescription self-
administered and self-collected use, FDA approved, authorized or cleared, one test count (K1034) provided 
July 12, 2023. 
 
You asked the Plan to pay for the OTC COVID-19 test. You say that you would appreciate prompt review of 
this appeal and approval of this approved service. The Plan denied your request. The Plan says over the counter 
(OTC) covid tests, K1034, are not covered by Medicare after May 11, 2023. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the OTC 
COVID-19 test is an OTC item. Therefore, we decided that the Plan does not have to pay for provision of 
COVID-19 test, nonprescription self-administered and self-collected use, FDA approved, authorized or cleared, 
one test count (K1034) provided July 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 20, 2023. 
 
You asked the Plan to pay for the lab services. You say that you provided medical records to support payment. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 84270, 84403, 
84402, and 82043 for February 27, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. There is no legible physician order. Without a 
record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed with code 
84270, 84403, 84402, and 82043 for February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae genetics testing (81404) provided May 26, 2023. 
 
You asked the Plan to pay for the genetic testing. 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 this test is not covered by Medicare.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Per DEX Diagnostics Exchange, the test has not been evaluated by 
the MolDx (Molecular Diagnostic tests) Programs technical assessment process. 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 Invitae genetics testing (81404) provided May 26, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (ECG) (93010) provided on June 19, 
2023. 
 
You asked the Plan to pay for the ECG. You say that code 93010 was billed correctly, and the claim should be 
paid. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported 
together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that R55 has an Excludes1 note in relation to I95.1. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the ECG have not been met. Therefore, we decided that the Plan does not have to pay for the 
electrocardiogram (ECG) (93010) provided on June 19, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing billed with codes 95937, 95938, 95939, 95860, and 
G0453 provided on June 20, 2023. 
 
You asked the Plan to pay for the tests. You say that codes 95937, 95938, 95939, 95860, and G0453 were 
billed correctly, and the claim should be paid. The Plan denied your request. The Plan says two of the billed 
diagnosis codes cannot be reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that M54.2 has an Excludes1 note in relation to M50.1. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the tests have not been met. Therefore, we decided that the Plan does not have to pay for 
testing billed with codes 95937, 95938, 95939, 95860, and G0453 provided on June 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service June 5, 2023.  
 
You asked the Plan to pay for procedure code 99291. You say that you disagree with the denial. 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 when an MUE has an MAI of 1, units in excess of the 
MUE are only payable when reported on a separate claim line with appropriate use of a modifier.  
 
In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 1. You billed 2 units of this code, exceeding the MUE. The units in excess of the MUE were not reported on a separate claim line with an 
appropriate modifier as required. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service June 5, 2023.