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

 
We decided that the Plan does not have to pay for the Urine PCR panel provided September 5, 2023, billed 
with codes 87500-59, 87641-59, 87798 x13, G0452-26, 87491-59, 87496-59, 87529-59, 87532-59, 87563-59, 
87591-59, 87481-59, 87651-59, 87653-59. 
 
You asked the Plan to pay for the laboratory testing. You say that you are an independent diagnostic laboratory 
that tests pathology, medication management and toxicology samples sent from clinics and providers for 
patients they have determined require such testing. 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. 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 Urine PCR panel provided September 5, 2023, billed with codes 87500-59, 
87641-59, 87798 x13, G0452-26, 87491-59, 87496-59, 87529-59, 87532-59, 87563-59, 87591-59, 87481-59, 
87651-59, 87653-59.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC (0315U) provided January 12, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that your claim for the DecisionDx-SCC test was 
denied in error and you are requesting it be reprocessed and paid. The Plan denied your request. The Plan says 
under Medicare guidelines, this testing 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 looked at the file and Medicare rules. MolDX will only cover and reimburse tests that demonstrate 
analytical and clinical validity, and clinical utility at a level that meets the Medicare reasonable and necessary 
requirement. This testing has undergone registration with Molecular Diagnostic Services Program (MolDX) 
and there is a denied Technical Assessment (TA) on file.  Based on this information, we decided that Medicare 
rules for coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the DecisionDx-SCC (0315U) provided January 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87481, 87500, 
87640, 87652, 87653, 87798, 87899, and 87900 for date of service July 6, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not payable 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 laboratory services billed with codes 87481, 87500, 87640, 87652, 87653, 
87798, 87899, and 87900 for date of service July 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 15, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the billed testing is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that MolDX will reimburse approved tests covered 
for dates of service consistent with the effective date of the coverage determination. 
 
We looked at the file and Medicare rules. The test billed in this case with DEX Z-code Z00D5 is not covered 
under DEX Diagnostics Exchange. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on August 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor, segmental home model with 
calibrated gradient pressure (E0652) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a pneumatic compressor. You say that you this patient needs a compression 
pump to continue maintenance at home and prevent this chronic conditioning to worsen. The Plan denied your 
request. The Plan says the records received do not indicate that the patient has an emergent or urgent medical 
condition, or is in need of specialized service(s) that are not available in-network. The Plan also says there are 
in-network provider(s) within a reasonable distance from the patient's location that can provide this service or 
item. 
 
 
 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compressor, segmental home model with calibrated gradient pressure (E0652) to be provided by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient clinic visit (G0463) provided on May 17, 
2023. 
 
You asked the Plan to pay for the outpatient clinic visit (G0463). You say that the service was medically 
necessary. 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 the outpatient clinic visit 
(G0463) provided on May 17, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic tests provided on February 03, 
2023, to June 09, 2023. 
 
You asked the Plan to waive the copayment for diagnostic tests. You say that the services should be covered. 
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 $25 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $25 copayment for diagnostic tests. This item/service falls within the outpatient 
diagnostic tests 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 diagnostic tests provided 
on February 03, 2023, to June 09, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77067 and 77063 billed for date of service 
July 31, 2023. 
 You asked the Plan to pay for procedure codes 77067 and 77063. You say that 77067 and 77063 should be paid 
as billed because they are supported in the documentation. The Plan denied your request. The Plan says 
payment for codes 77067 and 77063 is bundled into payment for code 77065. 
 
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 code 77065 was 
billed by the same provider or a provider of the same billing group on the same date of service as 77067 and 
77063. We have confirmed that codes 77067 and 77063 are column II codes to column I code 77065. 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 77067 and 77063 billed for date of service July 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99442) provided on April 22, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 code 99442 is "Telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 11-20 minutes of medical discussion". 
 
We find that CPT code 99442 is not supported in the medical record. Specifically, the records provided do not show that 11-20 minutes of medical discussion was spent with the enrollee during the services provided. 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 the services (99442) provided on April 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87500, 87641, 
87798, G0452, 87491, 87496, 87511, 87529, 87532, 87563, 87591, 87661, 87481, 87651, and 87653 provided 
on August 30, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable 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 laboratory services billed with codes 87500, 87641, 87798, G0452, 87491, 
87496, 87511, 87529, 87532, 87563, 87591, 87661, 87481, 87651, and 87653 provided on August 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 4, 2023, to 
February 7, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was accurately billed with the appropriate DRG. The Plan denied your request. The Plan says that the 
medical records did not have sufficient documentation to clinically validate the diagnosis of A41.9 (sepsis, 
unspecified organism). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.9 defined as sepsis, unspecified organism. 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 inpatient hospital services at the DRG 
originally billed. Our physician reviewer found that the sepsis-3 criteria were not met as there was insufficient 
evidence of organ failure directly related to a dysregulated response to systemic infection as required. 
Therefore, code A41.9 (sepsis) is not supported.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on February 4, 2023, to February 7, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT Solid Tumor Comprehensive Genomic 
Profiling (81456) provided on July 7, 2023. 
 
You asked the Plan to pay for the Tempus xT Solid Tumor Comprehensive Genomic Profiling. You say that 
this testing was medically necessary. The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that MolDX will reimburse approved tests covered 
for dates of service consistent with the effective date of the coverage determination. 
 
We looked at the file and Medicare rules. The billed test in this case is not a covered genetic test under DEX 
Diagnostics Exchange. Based on this information, we decided that Medicare rules for coverage of the Tempus 
xT Solid Tumor Comprehensive Genomic Profiling have not been met. Therefore, we decided that the Plan 
does not have to pay for the Tempus xT Solid Tumor Comprehensive Genomic Profiling (81456) provided on 
July 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on January 21, 2023. 
 
You asked the Plan to pay for the lab testing. You say that you are requesting reconsideration for the services 
provided. 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 the lab testing provided 
on January 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the pacemaker procedure provided on 
February 24, 2023, to February 25, 2023. 
 
You asked the Plan to reduce the coinsurance for the pacemaker procedure. You say that you disagree with the 
coinsurance. 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 50% 
coinsurance for out-of-network outpatient hospital services. 
 
You have been asked to pay 50% coinsurance for the pacemaker procedure. This item/service falls within the 
out-of-network outpatient hospital services 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. However, the total amount you owe is $5,550.30, which is less than 50% 
coinsurance of the allowed amount. Therefore, we decided that the Plan does not have to reduce the 
coinsurance for the pacemaker procedure provided on February 24, 2023, to February 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth visit provided on May 26, 2023. 
 
You asked the Plan to pay for the telehealth visit. You say that this was medically necessary. The Plan denied 
your request. The Plan says telehealth services performed out-of-network are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the telehealth visit have not been met. Therefore, we decided that the Plan does not have to pay for 
the telehealth visit provided on May 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the inpatient hospital stay provided on 
April 04, 2023, to April 21, 2023. 
 
You asked the Plan to reduce the coinsurance for the inpatient hospital stay. You say that you thought the 
provider was in-network. 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 40% 
coinsurance for out-of-network inpatient hospital care. 
 
You have been asked to pay 40% coinsurance for the inpatient hospital stay. This item/service falls within the 
out-of-network inpatient hospital care 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 $5,236.68 ($13,091.70 allowed amount x 40% = 
$5,236.68). Therefore, we decided that the Plan does not have to reduce the coinsurance for the inpatient 
hospital stay provided on April 04, 2023, to April 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prostate cancer screening; prostate specific antigen test 
(PSA) (G0103) provided June 28, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are unable to find another claim for 
G0103 within a month. The Plan denied your request. The Plan says this service exceeds the benefit maximum. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of a screening 
prostate antigen test once every 12 months.  
 
Based on review of the file, a PSA test was provided by another provider within 12 months to the visit at issue 
in this case. 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 prostate cancer screening; 
prostate specific antigen test (PSA) (G0103) provided June 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided February 
8, 2023, to March 1, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you disagree with this denial and 
believe these services were medically necessary. The Plan denied your request. The Plan says a PCD coded as 
E0675 is not eligible for reimbursement.  
 
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 a pneumatic compression device (E0675) provided February 8, 2023, to March 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the EsoGuard test (0114U) provided May 4, 2023. 
 
You asked the Plan to pay for the EsoGuard test . You say that you are the only provider of the EsoGuard test, 
and it is CLIA approved. The Plan denied your request. The Plan says this test is not covered. 
 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 Registry, the testing is considered 
non-covered after the Molecular Diagnostic tests (MolDX) program evaluation. Based on this information, we 
decided that Medicare rules for coverage of the EsoGuard test have not been met. Therefore, we decided that 
the Plan does not have to pay for the EsoGuard test (0114U) provided May 4, 2023.