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

 
We decided that the Plan does not have to pay for lab services (87637, 87502, 87651, 87641, 87150, 87500, 
87801) provided on May 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be billed as paid. 
 
The Plan must follow Medicare rules. Medicare rules say that a respiratory pathogen panel test is a single 
service with a single unit of service (UOS=1). A respiratory pathogen panel test must not be unbundled and 
billed as individual components. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. 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 (87637, 87502, 87651, 87641, 87150, 
87500, 87801) provided on May 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation, revision or repositioning of tunneled 
intrathecal or epidural catheter, for long term medication administration via an external pump or implantable 
reservoir/infusion pump; without laminectomy. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show that the catheter is not patent or is malfunctioning. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no indication to change the catheter at this time. The request has been made for both a pump 
change and a catheter change. The pump change has been approved but not the catheter change. There is no indication that the catheter is not functioning and there is no pump-o-gram which indicates non-patency. The 
request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long 
term medication administration via an external pump or implantable reservoir/infusion pump; without 
laminectomy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92944 billed for date of service December 9, 
2022. 
 
You asked the Plan to pay for procedure code 92944. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 92944 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 92944 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 92944 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 92944 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 92944 billed for date of service December 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Brovana. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the Part B drug is not eligible for a Part D tier exception. 
 
The Plan must follow Medicare rules. Medicare rules say that Part B drugs are not eligible for a Part D tier 
exception. 
 
We looked at the file and Medicare rules. The requested drug is covered by Part B Medicare and is not eligible 
for a Part D tier exception. Therefore, we decided that the Plan does not have to pre-approve a tier exception 
for Brovana.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 CDx genetic testing (0242U) billed for date of 
service July 21, 2021. 
 
You asked the Plan to pay for Guardant360 CDx genetic testing. You say that the services at issue have been 
billed correctly. 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. Based on this information, we decided that Medicare rules for coverage of Guardant360 CDx 
genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 
CDx genetic testing (0242U) billed for date of service July 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zolpidem. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zolpidem.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798 billed for date of 
service November 1, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653, and 87798. You say that you disagree with the 
denial. The Plan denied your request. The Plan says payment for codes 87481, 87653, and 87798 is bundled 
into payment for code 87801. 
 
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 
87481, 87653, and 87798 are a column II code to column I code 87801. 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 87481, 87653, and 87798 
billed for date of service November 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services billed with code 38525-AS for 
May 31, 2022. 
 
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 assistant surgeon services are not covered. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 38525. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon 
services billed with code 38525-AS for May 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drive wheel color insert, adapter interface plate, and 
foot plate connector. 
 
You asked the Plan to pre-approve drive wheel color insert, adapter interface plate, and foot plate connector. 
You say that the requested items are medically necessary for the enrollee. The Plan denied your request. The 
Plan says the requested items are for appearance, convenience, or comfort and therefore are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve drive wheel color insert, adapter 
interface plate, and foot plate connector. Our reviewer says that the requested drive wheel color insert, adapter 
interface plate, and foot plate connector are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the additional brackets and connector are part of the hardware for the foot plate and 
special cushion. The reviewer also found that a drive wheel color insert is for recreational purposes. Therefore, 
the reviewer found that the requested components are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of drive wheel color insert, adapter interface plate, and foot plate connector have 
not been met. Therefore, we decided that the Plan does not have to pre-approve drive wheel color insert, 
adapter interface plate, and foot plate connector.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flexible protective outer surface covering system. 
 
You asked the Plan to pre-approve flexible protective outer surface covering system. You say that you do not 
agree with the denial. The Plan denied your request. The Plan says the requested covering is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that protective outer surface covering systems are used by 
a beneficiary who has special needs for protection against unusually harsh environmental situations where it is 
necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by a standard 
cover. 
 
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 flexible protective outer surface covering system. Our reviewer says that a flexible protective outer surface covering system is not medically 
necessary. Our physician reviewer found the provided documentation does not support that you have special 
needs for protection against unusually harsh environmental situations where it is necessary to protect the lower 
limb prosthesis beyond the level of protection that is afforded by a standard cover. Therefore, the reviewer 
found that the requested cover is not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of flexible protective outer surface covering system have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a flexible protective outer surface covering system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D6740, D6245, D9944, D9612 and 
D2950) on May 16, 2022. 
 
You asked the Plan to pay for the dental services (D6740, D6245, D9944, D9612 and D2950). You say that 
you would like to request reconsideration of the denied claim. The Plan denied your request. The Plan says the 
services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services (D6740, D6245, D9944, D9612 and D2950) on May 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the procedure is currently approved as an ambulatory procedure. There 
is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight 
stay. 
 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found per the documentation; you have a rotator cuff arthropathy whose 
symptoms are refractory to conservative treatment. You are undergoing a planned total shoulder arthroplasty. 
You are medically stable and have been provided medical clearance to undergo this elective procedure. The 
planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List. The procedure is 
currently approved as an ambulatory procedure. There is no documentation provided to support the expectation 
that you will require a greater than 2 midnight stay. The review has determined that the record did not show 
that at the time of inpatient admission the admitting physician reasonably expected that your necessary hospital 
care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87900 billed for date of service November 8, 
2022. 
 
You asked the Plan to pay for procedure code 87900. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says this service is not supported in the medical record. 
 
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 87900 is infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics. 
 
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 procedure code 87900. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found the laboratory report does not include the quantitative 
prediction of the drug susceptibility phenotype for each antiretroviral drug with a numeric measure and 
assessment. This procedure was not documented and therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87900 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87900 billed for date of service November 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481,87641, 87653 and 87798 
billed for date of service November 4, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481,87641, 87653 and 87798. You say that these 
services were reported appropriately and are supported in the medical record. The Plan denied your request. 
The Plan says the payment for these services is included in the payment for other services billed on this claim. 
 
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 87150, 87481,87641, 87653 and 87798 are column II codes to 
column I codes 87500, 87801 and 87150. Codes 87481 and 87653 have not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met for codes 
87481 and 87653. However, codes 87150, 87641 and 87798 were each billed with a modifier.  
 
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 procedure codes 87150, 87641 and 87798. Our reviewer says 
that the use of the XU modifier is not supported for these services. Our reviewer found the laboratory does not 
include documentation to support these services as unusual non-overlapping services, and therefore the 
reported modifier cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87150, 87481,87641, 87653 and 87798 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87150, 87481,87641, 87653 and 
87798 billed for date of service November 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 19, 2022, billed 
with multiple codes including 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically 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 
September 19, 2022, billed with multiple codes including 81272.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and the bone 
replacement graft (D7953) for tooth #4 provided on September 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had a pre-authorization, and it was a 
medical emergency to get the dental services done. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because the guided tissue regeneration and the bone replacement graft are 
not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
guided tissue regeneration (D4266) and the bone replacement graft (D7953) for tooth #4 provided on 
September 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed on July 14, 2022. 
 
You asked the Plan to pay for code 99223. You say that this is supported in the records. The Plan denied your 
request. The Plan says the records do not document a comprehensive history. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
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 code 99223. Our reviewer says that the billed code is not 
supported. Our reviewer found the documentation shows a problem-focused expanded history and 
straightforward medical decision making. There is a more appropriate code for this service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed on July 14, 2022.