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

 
We decided that the Plan does not have to pay for procedure code J3490 billed for July 26, 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 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 20600 
provided on July 26, 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 procedure code J3490 billed for July 
26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on June 12, 2023, billed with 
codes 87798-59 x13, 87481-59 x 4, 87640-59, 87653-59. 
 
You asked the Plan to pay for the genetic testing billed. You say that your laboratory performed all the tests as 
per the order from the referring physician. 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. 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. The standard of care for the evaluation of urinary symptoms is urinalysis with urine culture and 
sensitivity. The PCR panel testing is considered excessive testing and not medically necessary. 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 laboratory testing provided on June 12, 2023, 
billed with codes 87798-59 x13, 87481-59 x 4, 87640-59, 87653-59.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that an Intracept procedure is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says an Intracept procedure is 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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no magnetic resonance imaging (MRI) report in the case record showing 
only modic changes without facet degenerative joint disorder (DJD) or stenosis. The cause of the enrollee's 
pain is not clear.  
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 (64628, 64629).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27335 billed for date of service April 26, 
2023. 
 You asked the Plan to pay for procedure code 27335. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 27335 is bundled into payment for code 27447. 
 
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 27335 
is a column II code to column I code 27447. 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 27335 billed for date of service April 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not have complicated wounds or 
multiple complicated medications which cannot be given in the current location. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the dental services (D7950 and D4266). 
 
You asked the Plan to pre-approve the dental services (D7950 and D4266). You say that you would like to 
request reconsideration of the denied dental services D7950 and D4266, and that the services requested are 
medically necessary. The Plan denied your request. The Plan says that the criteria for approval 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 (D7950 and D4266) 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 (D7950 and D4266). 
Our reviewer says that the service is medically necessary. Our physician reviewer found due to the lack of 
bilateral masticatory function; dental implants are to be placed. In order to achieve adequate bone for 
integration of the implant bodies, bone graft with guided tissue regeneration is medically reasonable and 
necessary.  This would provide adequate bone for integration of the implants and provide good bilateral 
masticatory function. 
 
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 (D7950 and D4266) have been met. Therefore, we decided 
that the Plan has to pre-approve the dental services (D7950 and D4266).  
 
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 January 31, 2023, billed with 
codes 81209-90, 81216-90, 81223-90, 81233-90 81238-90, 81241-90, 81242-90, 81249-90, 81250-90, 81279-
90, 81298-90, 81305-90, 81307-90, 81311-90, 81317-90, 81320-90, 81321-90, 81334-90, 81339-90, 81345-90, 
81479-90-GY. 
 
You asked the Plan to pay for the genetic testing billed. You say that please review the medical records and 
reprocess the claim. 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 
January 31, 2023, billed with codes 81209-90, 81216-90, 81223-90, 81233-90 81238-90, 81241-90, 81242-90, 
81249-90, 81250-90, 81279-90, 81298-90, 81305-90, 81307-90, 81311-90, 81317-90, 81320-90, 81321-90, 
81334-90, 81339-90, 81345-90, 81479-90-GY.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of extremity veins (93970) billed for date of 
service December 18, 2022.  
 
You asked the Plan to pay for the duplex scan. You say that medical records submitted support code 93970 and 
should be paid. 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 93970 is 1 unit. 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 
provided. The records submitted included two identical imaging reports with no evidence that two scans or two 
interpretations were performed. Based on this information, we decided that Medicare rules for coverage of 
procedure code 93970 have not been met. Therefore, we decided that the Plan does not have to pay for the 
duplex scan of extremity veins (93970) billed for date of service December 18, 2022.
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's medical condition requires further evaluation and 
treatment in the current acute care hospital, including tracking and trending of your hemoglobin to a stable 
level.  
 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
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: 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the records do not show the enrollee requires an intensive 
interdisciplinary care team to manage 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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel testing provided June 6, 2023, billed 
with codes 87150, 87481, 87641, 87653, 87798 and 87801. 
 
You asked the Plan to pay for the laboratory service. You say that kindly review the attached documents and 
process this claim towards possible payment. 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. 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 testing that was not billed with a single panel code 
as required. The standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and 
sensitivity. 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 Urine PCR panel testing 
provided June 6, 2023, billed with codes 87150, 87481, 87641, 87653, 87798 and 87801.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483, 80307) provided on April 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the codes 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 G0483, & 80307 are not supported in the medical record. Specifically, the records 
include lab results, however the records do not document the method used to perform the drug testing. 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 (G0483, 80307) provided on April 6, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Buzzaround CarryOn Folding Scooter (E1399), 
protection plan (E1399), and sales tax (S9999) purchased on March 27, 2023. 
 
You asked the Plan to pay for the Buzzaround CarryOn Folding Scooter, protection plan, and sales tax. You 
say that you were told something different each time you contacted the Plan trying to get reimbursed for your 
scooter. The Plan denied your request. The Plan says Medicare requires specific evaluations be done prior to 
approval of any power device, and you have not completed the necessary evaluations for approval of any 
power device. The Plan also says that sales tax and protection plans for durable medical equipment products 
are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that prior to or at the time of delivery of a POV or 
PWC, the supplier or practitioner must perform an on-site evaluation of the beneficiarys home to verify that 
the beneficiary can adequately maneuver the device that is provided. Medicare rules also say that Medicare 
does not make separate payment for sales tax. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Buzzaround CarryOn Folding Scooter, protection plan, and sales tax have not been met. 
Specifically, there was no physician signed seven element order, face to face examination with your provider, 
physician signed detailed product description order, physical/occupational therapy mobility device assessment, 
home assessment, or any documentation of a mobility limitation that significantly impairs your ability to 
participate in one or more mobilityrelated activities of daily living (MRADLs). Therefore, we decided that the 
Plan does not have to pay for the Buzzaround CarryOn Folding Scooter (E1399), protection plan (E1399), and 
sales tax (S9999) purchased on March 27, 2023.  
 
Your complaint about the Plan giving you and your provider the runaround is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology care to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve oncology care. You say that you are not being treated for your condition. 
The Plan denied your request. The Plan says this provider is out-of-network with the Plan and you can be 
treated within the Plan network. 
 
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 
oncology care 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 the Guardant Reveal (81479) provided on June 4, 2023. 
 
You asked the Plan to pay for the Guardant Reveal. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says  this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests such as the 
Guardant Reveal are subject to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. We find that the Guardant Reveal test has not been approved for 
coverage based on information in the DEX Diagnostic Exchange. 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 (81479) provided on June 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 80053, 81001, 
82043, 84480, 85025 and 36415 provided on June 22, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that because the independent laboratory service 
is medically necessary, your provider must perform the service at the time. The Plan denied your request. The 
Plan says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services billed with codes 80053, 
81001, 82043, 84480, 85025 and 36415 provided on June 22, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 30, 2023, billed with 
codes 81162-90, 81201-90, 81218-90, 81292-90, 81295-90, 81298-90, 81307-90, 81317-90, 81321-90, 81351-
90, 81209-90, 81314-90, 81334-90, 81345-90, 81272-90, 81479-90-GY x3. 
 
You asked the Plan to pay for the genetic testing billed. You say that please have a look at the attachment and 
reconsider the charges. 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 
January 30, 2023, billed with codes 81162-90, 81201-90, 81218-90, 81292-90, 81295-90, 81298-90, 81307-90, 
81317-90, 81321-90, 81351-90, 81209-90, 81314-90, 81334-90, 81345-90, 81272-90, 81479-90-GY x3.