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

 
We decided that the Plan does not have to pay for the laboratory services coded as 87481, 87900 and 87799-59 
provided August 3, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this test was ordered based upon the treating 
physician's clinical training and medical necessity. The Plan denied your request. The Plan says the billed 
codes does not meet Policy coverage criteria. CPT coded 87799 denied as procedure code was not performed. 
The more specific CPT code that represents this service was already reimbursed 
 
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 87481, is infectious agent detection by nucleic acid 
(DNA or RNA); Candida species, amplified probe technique; 87900 is infectious agent drug susceptibility 
phenotype prediction using regularly updated genotypic bioinformatics and 87799 is infectious agent detection 
by nucleic acid (DNA or RNA), not otherwise specified. 
 
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 laboratory testing. Our reviewer says that the billed 
services are not supported in the proved records. Our reviewer found for CPT 87481 the laboratory report does 
not support amplified probe technique. There is a more specific code to report for documented service. For 
CPT 87900, the laboratory report does not include documentation of infectious agent drug susceptibility 
phenotype prediction using regularly updated genotypic bioinformatics. Was unable to cite report, as procedure 
was not found in medical record. For CPT 87799 the procedure code represents not otherwise specified. The 
medical record should include procedures being billed under this procedure. Also, amplified probe technique is 
not supported in the laboratory report. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services coded as 87481, 87900 and 87799-59 provided August 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair-lift chair. 
 
You asked the Plan to pre-approve a stair-lift chair. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair-lift chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service July 24, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service July 24, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve custom fabricated abutments and abutment supported 
porcelain/ceramic crowns (D6057 x2, D6058 x2). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says that the services denied correctly as you 
do not meet the clinical requirements to be approved. 
 
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 Plan has not forwarded medical records to support their denial. 
Therefore, we decided that the Plan has to pre-approve custom fabricated abutments and abutment supported 
porcelain/ceramic crowns (D6057 x2, D6058 x2).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a center mount power elevating leg rest/platform 
(E1012) and electronic connection (E2311). 
 
You asked the Plan to pre-approve the items. You say that the enrollee requires a K0856 power wheelchair 
with tilt and an articulating foot platform. The Plan denied your request. The Plan says  the power leg lifts are not medically needed and cannot be covered. The Plan also says the upgraded electronics (electronic connector 
to 2 power options) 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 the items. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the items are not medically necessary as the enrollee has adequate strength to manage standard 
power drives. Furthermore, the enrollee does not have a contracture in the enrollee's knee or chronic edema. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a center mount power elevating leg rest/platform (E1012) and electronic connection (E2311).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the endoscopy to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the endoscopy. You say that you are requesting reconsideration.  The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be 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 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 
the endoscopy to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 80307 and G0483) 
rendered on June 6, 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 the denied codes 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 80307: 
 
Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), 
chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, 
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when 
performed, per date of service 
 
Healthcare Common Procedure Coding System (HCPCS) G0483: 
 
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 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 no provider records have been 
identified for review. Furthermore, the paperwork lists drug names, not clear results, thereby looking like a list 
of things to be tested, but not the results of testing. The denied codes are 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 laboratory services (procedure code 80307 and G0483) rendered on June 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 80307 and G0483 for date of service April 26, 2023. 
 
You asked the Plan to pay for codes 80307 and G0483. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 80307 is drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay 
[eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry 
either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, 
MALDI, TOF) includes sample validation when performed, per date of service. 

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 80307 and G0483 is not supported in the medical record. Specifically, the 
documentation includes an order for 22 or more drugs; however, the records provided do not include laboratory 
results to indicate that 22 or more drugs were performed. In addition the documentation does not include 
laboratory results for code 80307. Based on this information, we decided that Medicare rules for coverage of 
codes 80307 and G0483 have not been met. Therefore, we decided that the Plan does not have to pay for codes 
80307 and G0483 for date of service April 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller 
harness (E2313), and expandable controller (E2377). 
 
You asked the Plan to pre-approve the items. You say that the items listed in the Plan's denial letter that would 
meet the qualifications for recline were listed in the letter of medical necessity. You also say that you trust the 
provided documentation will be found sufficient to approve the equipment that provides a disabled patient with 
their only means of independence. The Plan denied your request. The Plan says although there are three 
requested power options (tilt, recline and elevating leg rests), there is not a medical need to control these power 
options through the joystick. 
 
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 items. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the items are not medically necessary as the enrollee has adequate strength to manage standard 
power drives.  
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an electronic connection (E2311), expandable controller harness (E2313), and expandable 
controller (E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller 
harness (E2313), expandable controller (E2377), and bracket assembly footplate width extension (K0108). 
 
You asked the Plan to pre-approve the items. You say that the items are medically necessary. The Plan denied 
your request. The Plan says although there are three approved power options on this wheelchair (tilt, recline 
and elevating leg rests), there is not a medical need to control these power options through the joystick. The 
Plan also says the bracket assembly footplate width extension (K0108) is miscoded and cannot be covered as 
these exceed the enrollee's need and are not reasonable and necessary per Medicare criteria. 
 
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 items. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the items are not medically necessary as the enrollee has adequate strength to manage standard 
power drives. 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 items have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311), expandable controller harness (E2313), 
expandable controller (E2377), and bracket assembly footplate width extension (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on March 22, 2023. We also decided that the Plan does not have to pay more for the crown - 
porcelain/ceramic (D2740) provided on March 22, 2023. 
 
You asked the Plan to pay for the core buildup. You also asked the Plan to pay more for the crown - 
porcelain/ceramic. You say that you located the provider from the plan list. You also are requesting the claim 
to be re-reviewed and to reverse the out-of-network processing. The Plan denied your request. The Plan says 
core buildup, including any pins when required is not a covered expense under your dental plan. The Plan also 
says that your benefit for the crown - porcelain/ceramic (D2740) dollar limit was partially met. 
 
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 core buildup, including any pins 
when required is not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for the core buildup, including any pins when required (D2950) provided on March 22, 2023.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. Specifically, 
the benefit for supplemental dental coverage is limited to $1,000 annually. The records show that the Plan paid 
$725 under claim number ending in 350501 for date of service March 22, 2023, and $275 under claim number 
ending in 99197 for dental services provided on May 3, 2023. This means the Plan has paid $1,000 in total for 
dental services provided in 2023. This exhausted the annual dental benefit allowance for the 2023 calendar 
year. Therefore, the Plan does not have to pay more for the crown - porcelain/ceramic (D2740) provided on 
March 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a folding travel scooter (K0899). 
 
You asked the Plan to pre-approve the folding travel scooter. You say that this equipment is medically 
necessary. The Plan denied your request. The Plan says this type of power scooter is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a power operated vehicle or power wheelchair 
which has not been reviewed by the Pricing, Data Analysis, and Coding (PDAC) contractor or which has been 
reviewed by the PDAC and found not to meet the definition of a specific POV/PWC will be denied as not 
reasonable and necessary and should be coded as K0899. 
 
We looked at the file and Medicare rules. This type of power scooter is code K0899 and is not covered. Based 
on this information, we decided that Medicare rules for coverage of the folding travel scooter have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a folding travel scooter (K0899).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 3, 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 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 lab services provided on January 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on March 16, 2023. 
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the service at issue was not billed with the required modifier to allow 
separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 17000 
provided on March 16, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99213) provided on 
March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 00630 provided on April 27, 2023. 
 
You asked the Plan to pay for procedure code 00630. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is 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 CPT code. 
 
We find that CPT code 00630 is not supported in the medical record. Specifically, the anesthesia code is 
included in the procedure performed and is not separately payable. Based on this information, we decided that 
Medicare rules for coverage of procedure code 00630 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 00630 provided on April 27, 2023.