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

 
We decided that the Plan does not have to pay for the Wound PCR panel coded as 87481, 87500, 87640, 
87641, 87651, 87653, 87798 x13, provided May 31, 2023.  
You asked the Plan to pay for the laboratory services. You say that you have provided additional supporting 
documentation and information which includes your lab reports and requisition are enclosed to support the test 
ordered and medical necessity. The Plan denied your request. The Plan says the documentation does not 
support that the services rendered were 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 pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the request does not meet Medicare coverage criteria because the testing is not FDA 
approved nor has the testing undergone registration with Molecular Diagnostic Services Program (MolDX). 
There is not an approved Technical Assessment (TA) on file on review date: October 27, 2023. The review has 
determined that the medical records provided do not support that the Wound PCR Panel meets the medically 
necessary requirements listed in the LCD for Medicare coverage. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pay for the Wound PCR panel coded as 87481, 87500, 87640, 87641, 87651, 87653, 87798 
x13, provided May 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure codes 81209 and 81218) 
rendered on June 13, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 81209 and 81218 remain 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 81209: 
 
BLM (Bloom syndrome, RecQ helicase-like) (eg, Bloom syndrome) gene analysis, 2281del6ins7 variant  
CPT 81218: 
 
CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (eg, acute myeloid leukemia), gene analysis, full 
gene sequence 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the laboratory report does not 
include documentation of the procedures reported. The procedures were not found in the documentation 
submitted. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services (procedure codes 81209 and 81218) rendered on June 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87481, 87640, 87651, 87653, and 87798) 
provided on August 18, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87640, 87651, 87653, and 87798. 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 say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the panel testing (87481, 87640, 87651, 87653, and 87798) provided on August 
18, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a romosozumab injection provided on July 
10, 2023. 
 
You asked the Plan to waive the coinsurance for a romosozumab injection. You say that you feel this has been 
overcharged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for a romosozumab injection. This item/service falls within the 
Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $435.54 ($2,177.70 x 20% = $435.54). Therefore, we decided that the 
Plan does not have to waive the coinsurance for a romosozumab injection provided on July 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on July 10, 2023. 
 
You asked the Plan to pay for wound care supplies. You say that these supplies are a separately billable 
expense that do not require authorization. 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 wound care supplies 
provided on July 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 2, 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 screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a hereditary breast cancer screening, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on July 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service August 10, 
2023. 
 
You asked the Plan to pay for procedure code 87640. You say that the codes are approved by Medicare. The 
Plan denied your request. The Plan says payment for code 87640 is bundled into payment for code 87641. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
In this case, we have confirmed that code 87640 is a column II code to column I code 87641. Code 87640 was 
billed with the -59 modifier. The records show that a wound panel test was provided. The records do not show 
that code 87640-59 was a separate and distinct procedure. 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 87640 
billed for date of service August 10, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on June 
29, 2023, and the observation services provided on June 30, 2023.    
 
You asked the Plan to waive the copayment for the emergency room visit and the observation services. You say 
that you do not think that you should have a copayment. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $75 
copayment for each emergency room visit, and a $15 copayment for Medicarecovered physician specialist 
services. 
 
You have been asked to pay a $75 copayment for the emergency room visit. This item/service falls within the 
emergency care benefit category. You have also been asked to pay a $15 copayment for the observation 
services. These items/services fall within the physician/practitioner services, including doctors office visits 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit 
provided on June 29, 2023, and the hospital observation services provided on June 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual depression screening (G0444) provided October 
2, 2023. 
 
You asked the Plan to pay for the annual screening. You say that you are appealing the denial of payment for a 
depression screening because you were seen by a nurse and did not have an annual test for depression at the 
previous appointment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $35 
copayment for specialist office or telehealth visits.    
You have been asked to pay $53.90 ($35 office visit copayment + $18.90 depression screening) for the annual 
screening. The records show that an annual depression screening was already provided on date of service May 
31, 2023. The benefit maximum for annual depression visits has been met and the specialist visit copayment for 
the office visit was applied. This item/service falls within the Physician/Practitioner services, including doctor's 
office visits benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to pay for the annual depression screening (G0444) 
provided October 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75774 billed for date of service August 18, 
2023. 
 You asked the Plan to pay for procedure code 75774. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 75774 is bundled into payment for code 37243. 
 
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 75774 
is a column II code to column I code 37243. The -59 modifier is not supported as a separate and distinct 
procedural service. 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 75774 billed for date of service August 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 5, 2023, billed with 
procedure code 01810-QK. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim is billed with an inappropriate diagnosis 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the 
condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the 
medical record, assign the code for the unspecified side.   
We looked at the file and Medicare rules. The claim has been reported with an unspecified diagnosis which is 
inappropriate when there is a more specific code available. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on June 5, 2023, billed with procedure code 
01810-QK.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 9, 2023, billed with 
code 81433. 
 
You asked the Plan to pay for the genetic testing billed with code 81433. You say that you have billed the 
services at issue correctly. 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 
with code 81433 have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on August 9, 2023, billed with code 81433.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a spinal injection provided on July 19, 
2023. 
 
You asked the Plan to waive the copayment for a spinal injection. You say that this was not a surgery. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for Medicare-covered surgery or other services provided at an ambulatory surgical center. 
 
You have been asked to pay a $225 copayment for a spinal injection. This item/service falls within the 
Medicare-covered surgery or other services provided at an ambulatory surgical center benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for a spinal injection provided on July 19, 2023.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 99222-AI. We decided that the Plan does not have to 
pay for procedure code 99232.  
 
You asked the Plan to pay for procedure codes 99222-AI and 99232 billed for dates of service May 11, 2023, 
to May 17, 2023. You say that these services were medically necessary and are supported in the records 
provided. The Plan says that no medical records were submitted for the dates in question to support that these 
services were necessary and were reported appropriately. 
 
We decided that the Plan has to pay for procedure code 99222-AI.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the records provided do include documentation for the date of 
service May 11, 2023. The Plan has not indicated or explained that the documentation provided does not 
support this service; they have only stated that no records were submitted for the date in question. However, 
there are clearly records dated May 11, 2023, in the case file for this enrollee. Therefore, we decided that the 
Plan has to pay for procedure code 99222-AI.  
 
We also decided that the Plan does not have to pay for procedure code 99232. 
 
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 procedure code 99232 billed for dates 
of service May 12, 2023, to May 17, 2023, have been met. Specifically, the records submitted for this enrollee 
only include a date of service of May 11, 2023. Without additional records, we cannot verify that the services 
provided were rendered as billed. Therefore, we decided that the Plan does not have to pay for procedure code 
99232. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each surgery service provided on August 
03, 2023, to August 18, 2023. 
 
You asked the Plan to reduce the copayment for each surgery service. You say that you should not be charged 
for surgery services and you disagree with the cost share. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities. 
 
You have been asked to pay a $325 copayment for each surgery service. This item/service falls within the outpatient surgery and other medical services provided at hospital outpatient facilities benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total amount you owe 
is $650 ($325 copayment x 2 procedures = $650). Therefore, we decided that the Plan does not have to reduce 
the copayment for each surgery service provided on August 03, 2023, to August 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 rendered from February 20, 2023, to 
August 15, 2023. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the records do not support the services 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 99214 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records for this case are rote, 
and do not convey medical decision making of moderate complexity. The records do not note the amount of 
time spent caring for the enrollee. As such, the billing of CPT 99214 is not supported. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99214 rendered from February 20, 2023, to August 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service code as 80053, 80061, 83036 84443, 
85025 provided June 14, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that please reprocess the claim. The Plan denied 
your request. The Plan says the criteria for coverage cannot be established. 
 
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 the laboratory service have been met. 
Additional records were needed to determine how the enrollee came to the servicing provider, whether the 
services were performed as billed, or whether the services are medically necessary. The records show the Plan 
made multiple attempts to obtain the information from the provider without success. Therefore, we decided that 
the Plan does not have to pay for the laboratory service code as 80053, 80061, 83036 84443, 85025 provided 
June 14, 2023.