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

 
We decided that the Plan does not have to pay for the genetic testing provided on May 30, 2023, billed with 
codes 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 30, 2023, billed with codes 81351.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power options (K0861), combination tilt and recline (E1007), center mount power elevating leg rest/platform 
(E1012), and electronic connection (E2311). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair, combination tilt and recline, center 
mount power elevating leg rest/platform, and electronic connection. The Plan denied your request. The Plan 
says based on Medicare guidelines, the replacement K0861 power wheelchair group 3 and related accessories 
requested does not meet the requirements for approval. 
 
The Plan follows Medicare rules. The rules say that replacement refers to the provision of an identical or nearly 
identical item. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple power options (such 
as code K0861) is covered if the criteria listed in the Medicare rules section of this letter are met. Medicare 
rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
 
 
 
 
 
 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 Group 3 standard power wheelchair, 
combination tilt and recline, center mount power elevating leg rest/platform, and electronic connection. Our 
reviewer says that the requested Group 3 power wheelchair is not medically necessary. Our physician reviewer 
found the case file does not contain records that support that the requested power wheelchair is replacement of 
an identical or nearly identical item that the enrollee has already been provided within the last 5 years. The 
available records do not support that the requested item is medically necessary due to a change in the enrollees 
medical condition. Our reviewer also found that the clinical documentation is insufficient to demonstrate that 
the enrollee in this case meets the coverage criteria for a K0861 power wheelchair. 
 
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 Group 3 standard power wheelchair, combination tilt and recline, center 
mount power elevating leg rest/platform, and electronic connection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple power options 
(K0861), combination tilt and recline (E1007), center mount power elevating leg rest/platform (E1012), and 
electronic connection (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on July 25, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 home visit provided on July 25, 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 laboratory panel billed with codes 87486, 87541, 87581, 
87640, and 87637 for date of service March 20, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable 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 the laboratory panel billed with codes 87486, 87541, 87581, 87640, and 87637 
for date of service March 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA OR 
RNA); gastrointestinal pathogen (87507) provided July 5, 2023 
 
You asked the Plan to pay for the laboratory service. You say that you were experiencing gastrointestinal 
problems and underwent both endoscopy and colonoscopy procedures. Pathology services were also required 
The Plan denied your request. The Plan says  procedure code 87507 has not met the associated diagnosis code 
relationship criteria. 
 
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 87507 is infectious agent detection by nucleic acid 
(deoxyribonucleic acid (DNA) or ribonucleic acid (RNA)); gastrointestinal pathogen (e.g., clostridium difficile, 
e. coli, salmonella, shigella, norovirus, giardia), includes multiplex reverse transcription, when performed, and 
multiplex amplified probe technique, multiple types or subtypes, 12-25 targets. 
 
We find that CPT code 87507 is not supported in the medical record. Specifically, per in Local Coverage 
Article A58963, CPT code 87507 is listed as a Group 2 code. However, the claim was billed with diagnosis code K52.9: noninfective gastroenteritis and colitis, unspecified. This diagnosis code is not listed in Local 
Coverage Article A58963 as a diagnosis code that supports medical necessity. 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 infectious agent detection by nucleic acid (DNA OR RNA); 
gastrointestinal pathogen (87507) provided July 5, 2023
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the reconstruction procedure provided on 
July 12, 2023. 
 
You asked the Plan to waive the coinsurance for the reconstruction procedure. You say that stated that the 
original consultation was charged at a in network cost and subsequently you received a bill for an out of 
network cost. You also stated that you tried to look for another provider who was in network with the Plan but 
there is no one in this area. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 40% 
coinsurance for out-of-network Medicare-covered outpatient surgery services. 
 You have been asked to pay $887.70 which is 40% coinsurance of the allowed amount for the reconstruction 
procedure. This service falls within the outpatient surgery benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for the  reconstruction procedure provided on July 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on September 28, 2023, billed 
with procedure code 11103. 
 
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 the add on code was billed without an appropriate 
primary procedure.  
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 11103 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for practitioner services provided on September 28, 2023, billed with procedure code 11103.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on August 1, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on August 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the oxygen concentrator and supplies 
rendered from July 3, 2023, to August 5, 2023. 
 
You asked the Plan to waive the coinsurance for these services. You say that the payments are a financial 
hardship. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment and related supplies form an in-network provider.  
 
Review of the file shows that you received an oxygen concentrator and supplies from July 3, 2023, to August 5, 
2023. You have been asked to pay a 20% coinsurance for these services. This item/service falls within the durable medical equipment and related supplies form an in-network provider benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. The file shows that the quote of $32.57 
was for the oxygen, not the oxygen concentrator and supplies. Therefore, we decided that the Plan does not 
have to waive the coinsurance for the oxygen concentrator and supplies rendered from July 3, 2023, to August 
5, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency department visit provided 
on August 05, 2023. 
 
You asked the Plan to waive the copayment for the emergency department visit. You say that the village of 
Bear Lake should be held financially responsible for this service. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 
copayment for emergency care. 
 
You have been asked to pay a $120 copayment for the emergency department visit. This item/service falls 
within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
emergency department visit provided on August 05, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 21, 2023, billed with 
codes 87481, 87640, 87653 and 87798. 
 
You asked the Plan to pay for laboratory services. 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. 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 laboratory services provided on August 21, 2023, billed with codes 87481, 
87640, 87653 and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custodial care provided on January 16, 2023, to February 28, 
2023. 
 
You asked the Plan to pay for custodial care. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the requested service is not covered under any condition. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of custodial care have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pay for custodial care 
provided on January 16, 2023, to February 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an orthovisc injection provided on August 
23, 2021. 
 
You asked the Plan to waive the coinsurance for an orthovisc injection. You say that you do not agree with the 
coinsurance. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicarecovered Part B chemotherapy drugs and other Part B drugs. 
 
You have been asked to pay 20% coinsurance for an orthovisc injection. This item/service falls within the 
Medicarecovered Part B chemotherapy drugs and other Part B drugs benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $53.98 ($269.90 
allowed amount x 20% = $53.98). Therefore, we decided that the Plan does not have to waive the coinsurance 
for an orthovisc injection provided on August 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 31, 2023, billed with 
codes 81456. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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. Review of the file shows that the enrollee also received services 
billed under code 81455. The records submitted indicate that the provider is requesting an additional code for a 
procedure that is part of another test that was performed. This means 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 July 31, 2023, billed with codes 81456.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided on March 
31, 2023, to April 20, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you disagree with the denial and 
have submitted medical records for review. The Plan denied your request. The Plan says the services are not 
covered. 
 
The Plan follows Medicare rules. The rules say that a PCD coded as E0675 will be denied as not reasonable 
and necessary. 
 
 
 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided 
on March 31, 2023, to April 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection (UTI) panel provided on August 
10, 2023, and billed with codes 87481, 87640, 87653, and 87798. 
 
You asked the Plan to pay for the UTI panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
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 urinary tract infection (UTI) panel provided on August 10, 2023, and billed 
with codes 87481, 87640, 87653, and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a residence visit provided on June 1, 2023, by an out-of-
network (OON) provider.  
 You asked the Plan to pay for the residence visit. You say that there was no opportunity to request 
authorization. The Plan denied your request. The Plan says that their original decision to deny payment was 
correct. 
 
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 a residence visit provided on June 1, 2023, by an 
OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a trabecular bone scan to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a trabecular bone scan with an out-of-network provider. You say that you 
want the Plan to approve this service. The Plan denied your request. The Plan says this need for this scan does 
not represent an urgent or emergent situation. The service would be approved with an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
   
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a trabecular bone scan to be provided by an out-of-network (OON) provider.