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

 
We decided that the Plan does not have to pay for the Tempus xT Gene panel (81455) provided January 21, 
2023. 
 You asked the Plan to pay for the genetic testing. You say that this letter and attached documents support the 
medical necessity of the test to assist in the treatment, prognosis, and diagnosis for the enrollee.  The Plan 
denied your request. The Plan says the Tempus xT Gene Panel shows no coverage through the MolDX 
program. 
 
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. The Tempus xT panel shows no coverage through the MolDX 
program. This means this test does not currently meet Medicare standards and cannot be covered. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the Tempus xT Gene panel (81455) provided January 21, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2. 
 
You asked the Plan to pre-approve a Freestyle Libre 2. You say that the item is necessary. The Plan denied 
your request. The Plan says only the preferred brand products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a Freestyle Libre 2. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 85060, 88311, 88313, 85097, 88305, and 
88360 billed for January 23, 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 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient.  
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8 and was not 
provided to a hospital inpatient. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that codes 88311, 88313, 85097, 88305, and 88360 
were billed with diagnoses that exclude each other. Therefore, we decided that the Plan does not have to pay 
for procedure codes 85060, 88311, 88313, 85097, 88305, and 88360 billed for January 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the EsoGuard testing (0114U) provided on June 23, 2023. 
 
You asked the Plan to pay for the EsoGuard testing. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory providers who bill molecular 
diagnostic tests must register test services on the DEX Diagnostics Exchange. 
 
We looked at the file and Medicare rules. The genetic testing in this case is not covered per the DEX 
Diagnostics Exchange. Based on this information, we decided that Medicare rules for coverage of the 
EsoGuard testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
EsoGuard testing (0114U) provided on June 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (86431) provided on April 1, 2023. 
 
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 paid as 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. 
 
We find that CPT code 86431 is not supported in the medical record. Specifically, the claim was not billed with 
the necessary KX modifier. 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 (86431) 
provided on April 1, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 
You asked the Plan to pre-approve Leqvio. You say that the enrollee will not be using this with a statin, and it 
is medically necessary for the enrollee. The Plan denied your request. The Plan says the only medically 
accepted use for Leqvio is when it is used in combination with a statin. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Leqvio. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the review has determined that the 
requested use of Leqvio is not FDA-approved for the enrollee's diagnosis. Its use is not supported by one of the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal. The medication 
request cannot be approved at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on May 13, 2023, and May 14, 
2023. 
 
You asked the Plan to pay for the medical services. You say that the diagnoses billed are payable. 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 J96.01 has an Excludes1 note in relation to R09.02. 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 May 13, 2023, and May 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on June 13, 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 G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 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 do not show that 
22 or more drug classes were tested on the date in question. 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 drug testing services provided on June 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GTI Wound PCR panel provided July 31, 2023, billed 
with codes 87500-59, 87641-59, 87798 x 13, G0452-26, 87471-59, 87481-59, 87551-59, 87651-59, 87653-59. 
 
You asked the Plan to pay for the laboratory testing. You say that please see the attached documents which 
contain all medical records pertaining to the date of service in question. The Plan denied your request. The Plan 
says panel testing should be billed using one CPT code on the claim. This test not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Additionally, in the DEX Diagnostics Exchange Registry, the testing is non covered per Molecular 
Diagnostics tests (MolDx) program evaluation. 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 GTI Wound PCR panel provided July 31, 2023, billed with codes 87500-59, 87641-59, 87798 x 13, 
G0452-26, 87471-59, 87481-59, 87551-59, 87651-59, 87653-59.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 16, 2023, billed with 
codes 81162, 81201, 81212, 81321, 81405, 81406, and 81408. 
 
You asked the Plan to pay for the genetic 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 an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 16, 2023, billed with codes 81162, 81201, 81212, 81321, 81405, 81406, and 81408.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 01916-QX-QS billed for date of service May 
20, 2023. 
 You asked the Plan to pay for procedure code 01916-QX-QS. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says payment for code 01916-QX-QS is bundled into 
payment for code 01924. 
 
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 
01916-QX-QS is a column II code to column I code 01924. 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 code 01916-QX-QS billed for date of 
service May 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing billed with codes 80355 and 80373 for June 
12, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that presumptive drug testing may be reported with CPT 
codes 80305-80307 and definitive drug testing may be reported with HCPCS codes G0480-G0483 and G0659. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the appropriate 
G code for drug testing. 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 the drug testing billed 
with codes 80355 and 80373 for June 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and appliance 
(E0667) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a pneumatic compression device (E0652) and appliance (E0667). You say 
that you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested items can be 
provided by a network provider. 
 
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 compression device (E0652) and appliance (E0667) 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 pre-approve an office visit to be provided by the requested 
physician. 
 
You asked the Plan to pre-approve an office visit to be provided by the requested physician. You say that you 
requested a referral from your PCPs office; however they would not give you a referral. The Plan denied your 
request. The Plan says this provider is in the Plan's network but not within the PCP's referral circle and the Plan 
does not have a referral on file for the member to see this provider. 
 
The Plan contract says each Plan PCP has certain Plan specialists called a referral circle that s/he uses for 
providing medical care to you. A referral circle is the team of specialists your PCP works with. If your PCP 
refers you to a specialist s/he will send you to a specialist in his/her referral circle. 
 
We looked at the file and the Plans rules. The file shows that the requested physician is not within your PCPs 
referral circle. Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided 
by the requested physician.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87481, 87491, 87563, 87640, 87653, 
87798, 87641, and 87500) provided on July 5, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500. 
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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500 are not supported in the 
medical record. Specifically, a panel was performed and there is a more appropriate singular code for the 
services. 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 the panel testing (87481, 87491, 87563, 
87640, 87653, 87798, 87641, and 87500) provided on July 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal testing billed with code 81479 for date 
of service May 30, 2023. 
 
You asked the Plan to pay for the Guardant Reveal. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 We find that the Guardant Reveal is the service at issue. This testing is specifically not covered. Based on this 
information, we decided that Medicare rules for coverage of the Guardant Reveal have not been met. 
Therefore, we decided that the Plan does not have to pay for the Guardant Reveal testing billed with code 
81479 for date of service May 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 29, 2023. 
 
You asked the Plan to pay for the dental services. You say that the Plan should pay more. The Plan denied your 
request. The Plan says your annual dental allowance amount has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your annual dental allowance amount was exhausted on date of service January 26, 2023. Therefore, we 
decided that the Plan does not have to pay for dental services provided on June 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0315U) provided on April 25, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this test is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will cover approved tests covered for 
dates of service consistent with the effective date of the coverage determination. 
 
We looked at the file and Medicare rules. DecisionDx-SCC was not listed as a covered test on the MolDX 
registry as of the date of service. Based on this information, we decided that Medicare rules for coverage of the 
genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing 
(0315U) provided on April 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on June 22, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration of the 
denied claim. 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 laboratory service 
provided on June 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 20, 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 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 office visit provided 
on April 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography provided on July 10, 2023, to July 
11, 2023. 
 
You asked the Plan to pay for the computed tomography. You say that you are requesting reconsideration of 
the denied claim. 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 computed 
tomography provided on July 10, 2023, to July 11, 2023.