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

 
We decided that the Plan does not have to pay for the laboratory panel (87634, 87581, 87801, 87150 and 
87541) billed for date of service January 18, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this was a laboratory panel which was not 
billed with a single panel code as required by Medicare billing guidelines. 
 
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 panel (87634, 87581, 87801, 87150 and 87541) billed for date of 
service January 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service July 26, 
2023. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 83789 is bundled into payment for code 80307. 
 
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 83789 
is a column II code to column I code 80307. The -59 modifier is not supported as a separate and distinct 
procedural service. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 83789 billed for date of service July 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ankle-foot orthosis (L1960). 
 
You asked the Plan to pre-approve an ankle-foot orthosis. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for an ankle-foot 
orthosis have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that AFO are covered for ambulatory beneficiaries 
with weakness or deformity of the foot and ankle, who: 
1. Require stabilization for medical reasons, and, 
2. Have the potential to benefit functionally. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an ankle-foot orthosis have not been met. Specifically, the provided medical records do not show 
that the enrollee is ambulatory. Therefore, we decided that the Plan does not have to pre-approve an ankle-foot 
orthosis (L1960).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87529, and 87640 billed for date of 
service June 29, 2023.  
 
You asked the Plan to pay for procedure codes 87481, 87529, and 87640. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the number of units billed 
exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 87481 is 5. The MAI value for this code is 3. You billed 7 units of this 
code, exceeding the MUE. The MUE for CPT code 87529 is 2. The MAI value for this code is 3. You billed 3 
units of this code, exceeding the MUE. The MUE for CPT code 87640 is 1. The MAI value for this code is 3. 
You billed 2 units of this code, exceeding the MUE. You did not provide all the required evidence showing that 
the excess units were actually provided, were correctly coded, and were medically necessary. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 87481, 87529, and 87640 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 87529, and 
87640 billed for date of service June 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve flex-walk system or equal (L5981), microprocessor 
control feature, swing and stance phase, includes electronic sensor(s), any type (L5856) single axis, fluid swing 
and stance phase control (L5828), stance flexion feature, adjustable (L5845), fluid stance extension, dampening 
feature, with or without adjustability (L5848), knee extension assist (L5850), manual lock (L5925). 
 
You asked the Plan to pre-approve the advanced knee and foot. You say that please review the additional 
information that has been provided and reconsider the denial so the enrollee can be provided with a prosthesis 
that will give them a chance to return to their pre-amputation lifestyle The Plan denied your request. The Plan 
says the current foot and knee are less than a year old and still under warranty and the records do not show that 
the requested foot and knee are medically needed and exceeds the enrollee's needs.  
 
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 K3 knee and foot. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee uses a wheelchair which is not consistent with K2 ambulation. The 
requested components are still under warranty. The documentation does not support that the enrollee would be 
unable to complete activities including ambulation on uneven terrain with K2 components. The documentation 
does not support that the enrollee requires computerized knee components which are less durable and provides 
for a heavier knee. The requested knee and ankle exceed the enrollee's medical needs. 
 
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 K3 knee and foot have not been met. Therefore, we decided that the Plan 
does not have to pre-approve flex-walk system or equal (L5981), microprocessor control feature, swing and 
stance phase, includes electronic sensor(s), any type (L5856) single axis, fluid swing and stance phase control 
(L5828), stance flexion feature, adjustable (L5845), fluid stance extension, dampening feature, with or without 
adjustability (L5848), knee extension assist (L5850), manual lock (L5925).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing, of 15-21 drug classes (G0482) 
provided July 7, 2023.  
 
You asked the Plan to pay for the laboratory testing. You say that the medical records attached to the appeal 
support the modifier usage and the charge is separate and distinct from other services listed on the claim. The 
Plan denied your request. The Plan says the condition of the enrollee did not meet the Medicare rules for 
approval of definitive urine drug testing (UDT) for 15-21 drug classes (HCPCS Code G0482). 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the laboratory testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is taking hydrocodone and gabapentin and may be at risk for other substances but 
the history and physical do not support extensive substance abuse. There is no preliminary testing indicating 
probability of multiple substances. The criteria have not been met as the history and physical and lab work do 
not support definitive urine drug testing.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the definitive drug testing, of 15-21 drug classes (G0482) provided July 7, 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 wheelchair accessories. You say that Medicare has reviewed the request and 
found the services to be both medically necessary and covered, under Medicare guidelines. You also say that 
the Plan should follow Medicare's decision and find this to be medically necessary. The Plan denied your 
request. The Plan says the electronic connection, expandable controller harness, and expandable controller 
cannot be covered as they are not medically necessary to control the three approved power options through the 
joystick (drive interface). 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has paraplegia and 5/5 strength in upper extremities. Per Medicare 
guidelines, the requested 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 wheelchair accessories 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: Favorable

 
We decided that the Plan has to pre-approve the Group 3 power wheelchair with multiple power options and 
accessories coded as K0861, E0955, E1007, E1012, E1028, E2311, E2313, E2323, E2361, E2377, E2615, 
E2624 and K0108.  
 
You asked the Plan to pre-approve the wheelchair. You say that the medical records provided will show proof 
of medical necessity. The Plan denied your request. The Plan says that the request for K0861 Group 3 power wheelchair with multiple power options is not reasonable and necessary as the enrollee does not have need for 
both power tilt and power recline.  
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested items/services is considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has rheumatoid arthritis, is non-ambulatory and has recently had stasis dermatitis. 
The enrollee is at high risk for skin breakdown and meets the LCD L33789 criteria for the requested Group 3 
wheelchair and accessories. 
 
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 wheelchair have been met. Therefore, we decided that the Plan has to pre-
approve the Group 3 power wheelchair with multiple power options and accessories coded as K0861, E0955, 
E1007, E1012, E1028, E2311, E2313, E2323, E2361, E2377, E2615, E2624 and K0108.   
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 10, 2023, billed with 
codes 81225, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 81335 and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 10, 2023, billed with codes 81225, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 81335 and 
81355.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that you would like to appeal the power 
wheelchair and its components for authorization for the enrollee. The Plan denied your request. The Plan says 
the requested joystick does not serve a primary medical purpose and is statutorily non-covered. 
 
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 a wheelchair accessory. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is weak, deconditioned, and short of breath. She feeds herself and is able 
to perform upper body bathing and grooming. Per Medicare guidelines, the requested item is 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 a wheelchair accessory have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fungal polymerase chain reaction (PCR) panel (87801, 
87798 and 87481) provided on March 9, 2023. 
 
You asked the Plan to pay for the fungal PCR panel. You say that this panel was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this test is not medically 
necessary as it has not been proven to be more effective than the current standard methods of testing. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the fungal PCR panel. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there was no explanation found in the provided notes to explain why supported 
methods of testing for fungal infection (KOH [Potassium hydroxide] prep, culture, stain, etc.) were not 
appropriate for this patient. PCR testing is not currently supported as superior to these standard methods. 
Therefore, the PCR testing is considered not medically 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 fungal PCR panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the fungal polymerase chain reaction (PCR) panel (87801, 87798 and 87481) provided 
on March 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot be home alone and your family does not 
have the experience to assist you with the injuries you sustained. You need rehabilitation to learn how to walk 
again to regain the quality of life prior to your injuries. The Plan denied your request. The Plan says your 
records do not show that you have ongoing complex rehabilitation needs which would require you to be seen 
three times 
a week by the rehabilitation physician to monitor your functional progress.  The Plan says services may be 
provided at a lower level of care.   
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical records 
support a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. It is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body: endosteal 
implant (D6010 x2) and a panoramic radiographic image (D0330). 
 
You asked the Plan to pre-approve the surgical placement of implant body: endosteal implant (D6010 x2) and a 
panoramic radiographic image (D0330). You say that you aren't able to eat and due to poor hygiene, it can 
cause infections. The Plan denied your request. The Plan says the surgical placement of implant body: 
endosteal implant is denied because this implant service is not a covered benefit under the plan. A panoramic 
radiographic image is denied because benefits for this service have been satisfied and the frequency limitation 
has been exceeded. 
 
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, certain limitations apply. The record 
shows your benefit for the panoramic radiographic image was exhausted on date of service March 9, 2023. In 
addition, endosteal implants are not among the services covered under this benefit. Therefore, we decided that 
the Plan does not have to pre-approve the surgical placement of implant body: endosteal implant (D6010 x2) 
and a panoramic radiographic image (D0330).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for practitioner services provided on October 12, 2022, billed with 
procedure codes 81162, 82195, 81297-59, 81298, and 81307. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that documentation does not support the billed 
codes. 
 
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 
codes 81162, 82195, 81297-59, 81298, and 81307 is MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 
1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis, 
MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, 
Lynch syndrome) gene analysis; duplication/deletion variants,MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary 
non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis, and PALB2 (partner 
and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; full gene sequence . 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the practitioner services provided. Our reviewer says that 
documentation does support the billed codes. Our reviewer found that pages 47-49 support the use of the lab 
codes 81162, 82195, 81297-59, 81298, and 81307, the description of the gene analysis included all sequences 
mentioned above in support. 
 
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 practitioner services provided have been met. Therefore, we decided that the 
Plan has to pay for practitioner services provided on October 12, 2022, billed with procedure codes 81162, 
82195, 81297-59, 81298, and 81307.  
 
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.