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

 
We decided that the Plan does not have to pay for the GeneDose Genetic Response report (comprehensive 
hereditary pharmacogenomic testing) and Hereditary Genetic Cardiac test panel provided June 23, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the clinical documentation 
provided does not meet the Medicare medically necessary 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 pay for the genetic 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, with type 2 diabetes, rheumatoid arthritis, and hypertension underwent 
comprehensive hereditary pharmacogenomic testing and hereditary genetic cardiac testing. However, the 
provided documentation did not include the proposed medication changes that would directly have a gene-drug 
interaction, or how the results would lead to a change in treatment or overall outcomes for this patient. 
Therefore, this request for the gene testing will be 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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the GeneDose Genetic Response report (comprehensive hereditary pharmacogenomic 
testing) and Hereditary Genetic Cardiac test panel provided June 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83036 for date of service April 24, 2023. 
 
You asked the Plan to pay for procedure code 83036. 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 83036 is Hemoglobin; glycosylated (A1C). 
 
We find that CPT code 83036 is not supported in the medical record. Specifically, the documentation submitted 
did not include documentation of hemoglobin; glycosylated (A1C) laboratory results. This means the billed 
service cannot be verified. Based on this information, we decided that Medicare rules for coverage of 
procedure code 83036 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 83036 for date of service April 24, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 38792 rendered on June 7, 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 that the documents received do not support that the procedure or service was distinct or 
independent from other services performed; therefore, the requested CPT modifier 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 38792 is "Injection procedure; radioactive tracer for identification of sentinel node." 
 
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 supported by the medical records.  Our reviewer found that the record supports that 38792 and 
38900 were performed at separate sites and are separate and distinct procedures. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure code 38792 rendered on June 7, 2023.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that this procedure would help with the 
enrollee's pain. The Plan denied your request. The Plan says this is an experimental procedure for the enrollee's 
condition. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without 
stenosis or facet joint disease. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 31, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83036) provided on May 23, 2023. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says insufficient 
information was provided to review this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
In this case medical records were not provided for review. Without this information we are unable to verify 
whether criteria for coverage are met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (83036) provided on May 23, 2023.
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 November 9, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that please review attached medical records to 
support services rendered. The Plan denied your request. The Plan says the documentation submitted did not 
include documentation of an order that supports performing a definitive drug test of 15 or more drug classes; 
therefore, the billed service cannot be verified. 
 
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 G0482 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 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; 15-21 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 laboratory service. Our reviewer says that the records do 
not support the billed service. Our reviewer found G0482 is not supported. The record does not support that 15-
21 drug classes were tested. There is a more specific code for the number of drug classes tested.  
 
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 service 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 November 9, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 81455 billed for date of service May 12, 2023. 
 
You asked the Plan to pay for procedure code 81455. You say that this test was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says that the payment for code 81455 is included in 
the payment for code 81456. 
 
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. Medicare rules also say that providers must report services correctly. Providers must report services 
with the appropriate CPT code.  
 
In this case, we have confirmed that code 81455 is the column one code to column two code 81456 with a 
modifier indicator of 0. The column two code is not payable. The column two code in this code pair is 81456. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the code denied in this case is the payable code in the code pair 
mentioned by the Plan. In addition, the Plan has provided no evidence to show that code 81456 was also billed 
for the enrollee on the date in question. Therefore, we decided that the Plan has to pay for procedure code 
81455 billed for date of service May 12, 2023.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on May 6, 2023, billed with 
procedure code 74177. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the requested documentation has not been 
provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the imaging services provided have 
been met. Specifically, the requested medical records have not been provided for review despite numerous 
requests made by the Plan. Therefore, we decided that the Plan does not have to pay for imaging services 
provided on May 6, 2023, billed with procedure code 74177.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail polymerase chain reaction (PCR) panel provided on 
March 1, 2023. 
 
You asked the Plan to pay for the nail PCR panel. You say that you were advised that this test would be 
covered. The Plan denied your request. The Plan says there is a lack of data to suggest these panels alter 
medical decision making. 
 
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 nail 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 current standard of care for investigation of onychomycosis in a toenail is to perform a 
KOH and or fungal culture to the specimen. These lab tests are inexpensive, sensitive, and specific. It is unclear as to why this enrollee's toenail required PCR testing when other less expensive and efficacious lab tests (KOH 
and fungal culture) are available. Therefore, the requested PCR testing of this enrollee's toenail was 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 the nail PCR panel have not been met. Therefore, we decided that the Plan does 
not have to pay for the nail polymerase chain reaction (PCR) panel provided on March 1, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 outpatient physical therapy (PT) visits to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve out-of-network PT. You say that you can hardly walk and this physical 
therapy is helping you walk. You say that this physical therapy is within walking distance and the in-network 
therapy is not in walking distance. The Plan denied your request. The Plan says because you are able to see a 
provider in-network that would meet your needs, having care with an in-network provider at an in-network 
facility would not be detrimental to your health, and it is not medically necessary for you to see a specialist or 
subspecialist outside of the network, the Plan is unable to approve your request. 
 
 
 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 12 
outpatient physical therapy (PT) visits to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27824 performed on May 13, 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 Current Procedural Terminology (CPT) code 27824 remains 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 27824 is "Arthrotomy, elbow, including exploration, 
drainage, or removal of foreign body." 
 
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 the enrollee had an ankle stirrup (with posterior short leg) splint with Ortho-Glass applied in the emergency department. However, this was for 
the fibular fracture noted on the x-rays. Therefore, the documentation does not support that CPT 27824: closed 
treatment of fracture of weight-bearing articular portion of the distal tibia (e.g., pilon or tibial plafond), with or 
without anesthesia was rendered in this case. 
 
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 procedure code 27824 performed on May 13, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a fixed bridge. 
 
You asked the Plan to pre-approve the dental services. You say that a bridge replacement is a covered benefit. 
The Plan denied your request. The Plan says that the criteria for coverage have not been met. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says 
that the request is medically necessary. Our physician reviewer found that the documentation indicates that 
there was a bridge in place replacing tooth number 7 which broke. A new bridge replacing tooth number 7 
using tooth number 11 as an abutment retainer is being requested. Tooth number 11 appears to have good bone 
support to be used as a retainer supporting the pontic for tooth number 7. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve a fixed bridge.  
 
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 definitive drug testing (G0483) billed for date of service May 
8, 2023. 
 
You asked the Plan to pay for definitive drug testing. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says this code is not supported as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of definitive drug testing have been met. 
Specifically, the records provided include only results of specimen validity testing and presumptive drug 
screening tests. There are no definitive drug test results included. Without this information, we cannot verify 
that these services were performed as billed. Therefore, we decided that the Plan does not have to pay for 
definitive drug testing (G0483) billed for date of service May 8, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the enrollee needs a computed tomography to stage disease 
progress. 
 
You asked the Plan to pre-approve . The Plan denied your request. The Plan says that this is an auto-forward 
because the Plan did not decide timely.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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. Our reviewer says that you need this 
medical item. Our physician reviewer found a CT scan is/was medically reasonable and necessary and should 
be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of have been met. Therefore, we decided that the Plan has to pre-approve the 
enrollee needs a computed tomography to stage disease progress.  
 
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.