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

 
We decided that the Plan does not have to pay for the Tempus xT genetic testing provided on June 27, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that MolDX will reimburse approved tests covered 
for dates of service consistent with the effective date of the coverage determination. 
 
We looked at the file and Medicare rules. The billed test in this case is not a covered genetic test under DEX 
Diagnostics Exchange. Based on this information, we decided that Medicare rules for coverage of the testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xT genetic testing 
provided on June 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT comprehensive genomic profiling testing 
(81455) provided on June 6, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the genetic testing. You say that this letter and the attached documents support 
the medical necessity of the test, to assist in the treatment, prognosis and diagnosis for the enrollee. 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 Tempus xT comprehensive genomic profiling 
testing (81455) provided on June 6, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, the ophthalmic diagnostic imaging, and the 
visual field examination provided on April 4, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit, the ophthalmic diagnostic imaging, and the visual field 
examination. You say that you are appealing this denial. The Plan denied your request. The Plan says the 
provider is out-of-network and there was no 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 did not pre-approve the 
services. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for the office visit, the ophthalmic diagnostic imaging, and the visual field 
examination provided on April 4, 2023, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 26, 2023, to 
July 27, 2023.  
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and the rules. The claim was billed with a type of bill 322. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from July 26, 2023, to July 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0481 billed for date of service July 28, 
2023.  
 
You asked the Plan to pay for procedure code G0481. The Plan denied your request. The Plan says payment for 
code G0481 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 G0481 is a column two code to column one code 80307 with a modifier indicator of 0. The column two code is 
therefore not payable. 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 G0481 billed for date of service July 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87640, 87652, 87798, and 87799 
provided on July 24, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87640, 87652, 87798, and 87799. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services are not covered 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 procedure codes 87481, 87640, 87652, 87798, and 87799 provided on July 24, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on December 31, 2022, to 
January 1, 2023. 
 
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 expenses incurred in different calendar years 
cannot be processed as a single claim. A corrected claim must be submitted. 
 
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 practitioner services provided have 
been met. Specifically, a corrected claim has not been submitted. Therefore, we decided that the Plan does not 
have to pay for practitioner services provided on December 31, 2022, to January 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet light therapy system provided on May 18, 
2023. 
 
You asked the Plan to pay for the ultraviolet light therapy system. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that the documentation submitted does not support the diagnosis billed. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the ultraviolet light therapy system provided on 
May 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the item rendered is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service.  
 
 
 
 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. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 billed for date of service July 27, 
2023.  
 
You asked the Plan to pay for procedure code G0482. The Plan denied your request. The Plan says payment for 
code G0482 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 G0482 is a column two code to column one code 80307 with a modifier indicator of 0. The column two code is 
therefore not payable. 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 G0482 billed for date of service July 27, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from April 18, 2023, through 
August 1, 2023, by provider not eligible for Medicare. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider is a private company and not enrolled in Medicare. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that 
the Plan does not have to pay for the medical services provided from April 18, 2023, through August 1, 2023, 
by provider not eligible for Medicare.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97110 billed for date of service August 14, 
2023. 
 You asked the Plan to pay for procedure code 97110. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says payment for code 97110 is bundled into payment for 
code 97763. 
 
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 97110 
is a column II code to column I code 97763. 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 97110 billed for date of service August 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (86695, 86696, 86780, 87150, 87481, 
87491, 87500, 87590, 87624, 87625, 87641, 87798 and 87808) billed for date of service May 30, 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 the unbundling of lab codes for panel testing is 
not appropriate. 
 
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 was a panel. 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 (86695, 86696, 86780, 87150, 87481, 87491, 87500, 87590, 87624, 87625, 87641, 
87798 and 87808) billed for date of service May 30, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 26, 2023.  
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim was not billed with a correct type of bill. 
 
The Plan follows Medicare rules. The rules say that home health services must be billed with a correct type of 
bill. 
 
We reviewed the file and the Medicare rules. We find that the type of bill on the claim submitted was 0323. 
This is an incorrect type of bill code. Based on this information, we find that the Medicare rules for payment of 
the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home 
health services provided from June 26, 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 June 6, 
2023. 
 
You asked the Plan to pay for the UTI 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 amplified 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 June 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services described by code 0089U billed on date 
of service April 10, 2023. 
 
You asked the Plan to pay for 0089U. You say that 0089U should be paid as billed because it is supported in 
the documentation. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of 0089U have not been 
met. Therefore, we decided that the Plan does not have to pay for laboratory services described by code 0089U 
billed on date of service April 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43255 billed for date of service December 
26, 2022. 
 You asked the Plan to pay for procedure code 43255. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 43255 is bundled into payment for code 43239. 
 
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 43255 
is a column II code to column I code 43239. 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 43255 billed for date of service December 26, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 billed for date of service July 19, 
2023.  
 
You asked the Plan to pay for procedure code G0482. The Plan denied your request. The Plan says payment for 
code G0482 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 G0482 
is a column two code to column one code 80307 with a modifier indicator of 0. The column two code is therefore not payable. 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 G0482 billed for date of service July 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 2, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. 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 2, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335 and 81479.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided April 17, 2023 to May 16, 
2023. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim was not billed with required elements. 
 
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 the home health services are not supported. Specifically, the claim was submitted without a "Q" 
code for the first billable visit. Based on this information, we decided that Medicare rules for coverage of the 
home health services have not been met. Therefore, we decided that the Plan does not have to pay for home 
health services provided April 17, 2023 to May 16, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0481 billed for date of service July 19, 
2023.  
 
You asked the Plan to pay for procedure code G0481. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says payment for code G0481 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 G0481 is a column two code to column one code 80307 with a modifier indicator of 0. The column two code is 
therefore not payable. 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 G0481 billed for date of service July 19, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for CPT code A9270 provided during the CT scan provided on  
June 22, 2023. 
 
You asked the Plan to pay for CPT code A9270. You say that you do not know of any self-administered drugs 
provided to you during the CT scan and you were never informed that such services would not be covered. The 
Plan denied your request. The Plan says that self-administered medications are not covered by Medicare Part B 
in an outpatient setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan has not provided documentation showing that self-
administered drugs were provided during the CT scan or that you were notified before the CT scan that the 
services would not be covered. Therefore, we decided that the Plan has to pay for CPT code A9270 provided 
during the CT scan provided on June 22, 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.