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

 
We decided that the Plan does not have to pay for the Decipher prostate assay (81452, 88381) provided on 
April 27, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that you are requesting in-network coverage for 
an out-of-network referral. The Plan denied your request. The Plan says the Medicare criteria have not been 
met. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. There is also no documentation indicating that the enrollee has life expectancy of greater 
than or equal to 10 years or that the enrollee has a biochemically recurrent adenocarcinoma of the prostate.   
We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that 
the Plan does not have to pay for the Decipher prostate assay (81452, 88381) provided on April 27, 2023, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the urine polymerase chain reaction (PCR) panel testing 
provided on June 15, 2022. 
 
You asked the Plan to pre-approve the urine PCR panel testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says the PCR testing is considered unproven and 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 the urine PCR panel testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the limited provided documentation did not clearly describe the 
reasoning or clinical history/physical suggesting UTI was likely, nor why urinalysis and urine culture would 
not be sufficient for testing this individual which would be the standard of care in this clinical situation. PCR 
testing does not currently have sufficient evidence to support being superior to the current standard testing for 
UTI. Therefore, this request for urine PCR testing will be considered not medically necessary at this time and 
based on the provided documentation.  
 
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 urine PCR panel testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the urine polymerase chain reaction (PCR) panel testing provided on June 
15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for May 9, 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 separately payable. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 identifies technical component only standalone codes. 
 
We looked at the file and Medicare rules. Billed procedure code 99153 has a PC/TC indicator of 3 and no 
separate PC payment. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99153 billed 
for May 9, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service April 24, 
2023.  
 
You asked the Plan to pay for procedure code 76642. You say that the claim is billed correctly and should be 
paid. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 5, 2023. 
 
You asked the Plan to pay for the medical services. You say that these services were rendered in an emergency. 
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 R41.0 has an Excludes1 note in relation to R41.82. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the medical services have not been met. Therefore, we decided that the Plan does not have to 
pay for medical services provided on February 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) billed for date of service 
November 1, 2021. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary and are supported in the 
medical record. The Plan denied your request. The Plan says the number of classes reported in this case are not 
supported in the records provided. There is a more accurate code to report the services documented in this case. 
 
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 G0483 is drug test(s), definitive, 22 or more drug 
class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records support that 
drugs from only 16 classes were tested in this case. There is a more specific code for this service. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we 
decided that the Plan does not have to pay for definitive drug testing (G0483) billed for date of service 
November 1, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G2067 billed for date of service May 25, 2023. 
 
You asked the Plan to pay for the billed services. You say that the claim was denied in error. The Plan denied 
your request. The Plan says that the facility is not enrolled in a Medicare-enrolled opioid treatment program. 
 
The Plan must follow Medicare rules. The rules say that for an OTP to participate and receive payment, the 
OTP must be enrolled under section 1866(j) of the Act and be accredited by an accrediting body approved by 
SAMHSA. 
 
We looked at the file and the rules. The claim shows that the billing provider is an accredited OTP facility and 
participates in Medicare. This was submitted on a professional claim which is allowed according to the rules. 
Based on this information, we decided that the Medicare rules for coverage have been met. Therefore, we 
decided that the Plan has to pay for procedure code G2067 billed for date of service May 25, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341 and 88342 billed for date of service 
July 3, 2023. 
 You asked the Plan to pay for procedure codes 88341 and 88342. The Plan denied your request. The Plan says 
payment for codes 88341 and 88342 is bundled into payment for code 88360. 
 
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 
88341 and 88342 are column II codes to column I code 88360. This claim has not been billed with an 
appropriate modifier to bypass the edit. 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 codes 88341 and 88342 billed for 
date of service July 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service March 26, 
2023, to April 20, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service March 26, 2023, to April 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (64624). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging 
guidance. You say that this is medically necessary. The Plan denied your request. The Plan says this is not 
medically necessary because based on the medical literature this procedure is considered experimental or 
investigational and has not been proven to be beneficial for the enrollee's condition. 
 
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 destruction by neurolytic agent, 
genicular nerve branches including imaging guidance. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve 
ablation is experimental for knee pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction by neurolytic agent, genicular nerve branches including imaging 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by 
neurolytic agent, genicular nerve branches including imaging guidance, when performed (64624).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on February 15, 2023, billed with 
codes 87471, 87481, 87493, 87500, 87529, 87561, 87563, 87640, 87641, 87651, 87653, & 87798. 
 
You asked the Plan to pay for the lab testing billed. You say that this service was medically necessary. 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 a 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 lab testing billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab testing provided on February 
15, 2023, billed with codes 87471, 87481, 87493, 87500, 87529, 87561, 87563, 87640, 87641, 87651, 87653, 
& 87798.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 66984 billed for date of service May 1, 2023.  

You asked the Plan to pay for procedure code 66984. You say that these services were necessary and are 
supported in the medical record. 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 66984 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 66984 have not been met. Please note that one unit of code 66984 was paid to this provider on 
May 19, 2023. Therefore, we decided that the Plan does not have to pay for procedure code 66984 billed for 
date of service May 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient rehabilitation facility (IRF) services provided 
from January 5, 2023, through January 27, 2023.  
 
You asked the Plan to pay for the IRF services. You say that this was billed correctly and should be paid.  The 
Plan denied your request. The Plan says the occurrence code 74 incorrectly indicates the dates of the leave of 
absence.  
 
The Plan must follow Medicare rules. Medicare rules say that providers reporting leaves of absence on a 
hospital claim must reported the date span of the absence under occurrence code 74. 
 
We looked at the file and Medicare rules. Review of the claim shows that the date range listed in occurrence 
code 74 was January 6, 2002, to January 6, 2023. As this was entered in error, the claim was correctly denied. 
Based on this information, we decided that Medicare rules for coverage of the IRF services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient rehabilitation facility (IRF) services 
provided from January 5, 2023, through January 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E2311, E2313, E2377, E0955, E1007, 
E1012, E1028 x2, E2361, and E2603). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair with multiple power options and 
additional items and accessories. You say that you would like the power wheelchair and other parts to be 
considered for approval as you feel it would be medically beneficial for the enrollee. The Plan denied your 
request. The Plan says the enrollee does not have medical need for multiple power options included with a 
K0842 Group 2 power wheelchair. The Plan also says the electronic connection, expandable controller and 
expandable controller harness cannot be covered as it is not medically necessary to control the three requested 
power options through the joystick (drive interface).  
 
The Plan follows Medicare rules. Medicare rules say that he rules say that a Group 2 Multiple Power Option 
PWC (such as code K0842) or a Group 3 PWC with multiple power options (such as code K0861) is covered if 
the criteria listed in the Medicare rules section of this letter are met. Medicare rules also say that if the PWC 
base is not covered, then related accessories will be denied.  
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 Group 3 standard power wheelchair 
with multiple power options and additional items and accessories. Our reviewer says that the enrollee does not 
meet the criteria for coverage. Our physician reviewer found the enrollee has vertigo and impaired ambulation. 
The enrollee is considered not safe to use a scooter. Our reviewer found that the enrollee is continent and can 
stand and perform toileting independently with mobility assistance. The enrollee does not require a group 2 or 
group 3 power wheelchair as they are not at high risk for skin breakdown, use a catheter or have spasticity 
compromising positioning. Our physician reviewer also found that the enrollee does not require power tilt or 
tilt and recline nor do they have a qualifying diagnosis for a group 3 wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Group 3 standard power wheelchair with multiple power options and 
additional items and accessories have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Group 3 standard power wheelchair with multiple power options (K0861) and additional items and 
accessories (codes E2311, E2313, E2377, E0955, E1007, E1012, E1028 x2, E2361, and E2603).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ViviGen allograft (20930). 
 
You asked the Plan to pre-approve a ViviGen allograft. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the ViviGen allograft in the setting of 
anterior cervical spine fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 a ViviGen allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows 
this requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies are 
needed to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ViviGen allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a ViviGen allograft (20930).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nonpneumatic compression controller with sequential 
calibrated gradient pressure (K1024) and a nonpneumatic sequential compression garment, full arm (K1025). 
 
You asked the Plan to pre-approve a nonpneumatic compression controller and garment. You say that you are 
requesting reconsideration and have submitted medical records for review. The Plan denied your request. The 
Plan says a review of the current medical literature does not consider this Dayspring device to be standard 
medical treatment for the management of lymphedema. 
 
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 a nonpneumatic compression controller 
and garment. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found provided medical records and review of the current peer-
reviewed medical literature do not document that use of the Dayspring device and garments has been shown in 
controlled studies in a Centers for Medicare and Medicaid Services (CMS)-approved journal to result in long 
term health benefits in enrollees with lymphedema. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a nonpneumatic compression controller and garment have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a nonpneumatic compression controller with 
sequential calibrated gradient pressure (K1024) and a nonpneumatic sequential compression garment, full arm 
(K1025).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 15, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied claim. The Plan denied your request. The Plan says this service was not authorized.. 
 
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 service at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit provided on May 15, 2023, by an out-of-network provider.