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

 
We decided that the Plan does not have to pay for drug testing (G0481) billed for date of service April 6, 2023. 
 
You asked the Plan to pay for drug testing. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says the provided records do not support the service 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 drug testing have been met. 
Specifically, a detailed itemization of the tests involved in the panel at issue is not evident in the case record. 
The billed service cannot be verified. Therefore, we decided that the Plan does not have to pay for drug testing 
(G0481) billed for date of service April 6, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Guardant360 testing (81479) provided on April 23, 2023. 
 
You asked the Plan to pay for the Guardant360 testing (81479). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered as billed. 
 
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. The rules also 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. The rules also 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. 
 
We looked at the file and Medicare rules. Review of the claim does show that the required unique identifier 
was reported. Additionally, this was an NGS panel that was billed with a single panel code as required. 
Although, a different procedure code is recommended by the DEX, the Plan has not provided any evidence that 
procedure code 81479 is not payable in this case. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing (81479) have been met. Therefore, we decided that the Plan has to pay for 
the Guardant360 testing (81479) provided on April 23, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 24, 2023, billed with 
codes 81238, 81226, 81225, 81306, 81328, 81335, 81231, 81277, 81232 and 81241. 
 
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 
March 24, 2023, billed with codes 81238, 81226, 81225, 81306, 81328, 81335, 81231, 81277, 81232 and 
81241.
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 July 6, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says this is a non-covered service. 
 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 July 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies billed with codes E0601, A4604, A7038, E0562, 
A7030, A7035, and A7031 for date of service May 23, 2023. 
 
You asked the Plan to pay for supplies billed with codes E0601, A4604, A7038, E0562, A7030, A7035, and 
A7031. 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 a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the documentation did not include an enrollee receipt or proof of delivery for the billed date of 
service. 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 supplies billed with codes E0601, A4604, 
A7038, E0562, A7030, A7035, and A7031 for date of service May 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92541 for date of service June 27, 2023. 
 
You asked the Plan to pay for procedure code 92541. 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 services must be billed correctly. 
 
We looked at the file and Medicare rules. Review of the file shows that code 92541 was billed with modifier 
GP. This service provided is not outpatient physical therapy. It is not appropriate to bill GP modifier with non-
therapy procedures. Based on this information, we decided that Medicare rules for coverage of procedure code 
92541 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 92541 
for date of service June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 96372 billed for date of service July 1, 2023. 
 
You asked the Plan to pay for code 96372. You say that this is a payable code. The Plan denied your request. 
The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that STV-packaged services are services for which separate 
payment is made only if there is no service with status indicator S, T, or V reported on the same claim. If a 
claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. In this case, the code in dispute has a status indicator of QI, meaning 
that it is a STV-packaged service.  This disputed code was billed on the same claim with a code that has a status indicator of S, T, or V.  This means that the code in dispute in this appeal is not separately payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 96372 have not been met. Therefore, we decided that the Plan does not have to pay for code 
96372 billed for date of service July 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty at T10. 
 
You asked the Plan to pre-approve kyphoplasty at T10. You say that the repulsion is mild, which is common 
with compression fractures, and the safety of kyphoplasty is not compromised.  The Plan denied your request. 
The Plan says  is not medically necessary. The Plan says the record shows 50% loss of anterior vertebral height 
and minimal repulsion.  
 
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 kyphoplasty at T10. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was being treated for age-related osteoporosis with current pathological fracture. 
However, detailed documentation is not evident clearly evidencing undergoing treatment for osteoporosis. 
Additionally, there is no documentation of a progression of the body height loss, kyphotic deformity, or a 
severe impact on daily activities. Moreover, there is magnetic resonance imaging (MRI) (exclusion criteria) 
corroboration of retropulsion and other plausible causes of pain. Therefore, the enrollee does not meet all 
criteria for kyphoplasty. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty at T10 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve kyphoplasty at T10.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR testing provided January 27, 2023, billed with 
codes 87481, 87653, 87798 x12, 87801 x3. 
 
You asked the Plan to pay for the laboratory testing. 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 that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the Urine PCR testing provided 
January 27, 2023, billed with codes 87481, 87653, 87798 x12, 87801 x3.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on May 31, 2023. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that S00.431A has an Excludes1 note in relation to S01.311A. This means that 
the two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the medical services have not been met. Therefore, we decided that the Plan does not have to 
pay for medical services provided on May 31, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Ilumya injections. 
 
You asked the Plan to pre-approve Ilumya injections. You say that the enrollee's condition would benefit from 
the requested injections. The Plan denied your request. The Plan says that the enrollee does not meet the 
necessary medical requirements to support the need for the service requested. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary. The rules also say that if a Plan decides to apply step 
therapy requirements to Part B drugs, they must disclose that information in the ANOC and EOC documents. 
 
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 Ilumya injections. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found that coverage for Ilumya was denied by the Plan, as the enrollee did not meet the 
medical necessity criteria and the enrollee has not trialed the required drugs Cosentyx, Enbrel, Humira, Stelara, 
or Otezla. However, a step-therapy disclosure for Part B drugs is not included in the provided Evidence of 
Coverage (EOC) so the review is based on whether Ilumya is medically reasonable and necessary for the 
enrollee. In this case, the medical records provided, and the Medicare-approved major drug compendia support 
that Ilumya is medically reasonable and necessary, safe and effective, and Food and Drug Administration 
(FDA) approved for the patients diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya injections have been met. Therefore, we decided that the Plan has to 
pre-approve Ilumya injections.  
 
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 laboratory services rendered on May 10, 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 two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that E11.9 has an Excludes1 note in relation to R73.03. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for these services have not been met. Therefore, we decided that the Plan does not have to pay for 
the laboratory services rendered on May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (00812) provided on July 18, 2023. 
 
You asked the Plan to pay for the anesthesia services (00812). You say that the services should be covered. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the anesthesia services 
(00812) provided on July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service September 
23, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this is a billable and payable code. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service September 23, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 90471 and 90715 billed for date of service June 27, 
2023. 
 
You asked the Plan to pay for codes 90471 and 90715. You say that these are payable codes. The Plan denied 
your request. The Plan says these codes are not separately payable.  
The Plan must follow Medicare rules. The rules say that STV-packaged services are services for which separate 
payment is made only if there is no service with status indicator S, T, or V reported on the same claim. If a 
claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. In this case, code 90471 has a status indicator of QI, meaning that it is 
a STV-packaged service.  Code 90471 was billed on the same claim with a code that has a status indicator of S, 
T, or V.  This means that code 90471 is not separately payable. 
 
In relation to code 90715, Medicare rules state that codes with status indicator of N are considered packaged 
services, and no separate payment is made for these codes. Code 90715 has a status indicator of N, so no 
separate payment can be made for this code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes 90471 and 90715 have not been met. Therefore, we decided that the Plan does not have to 
pay for codes 90471 and 90715 billed for date of service June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 27, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 27, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine provided on January 20, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that bupivacaine was a medical necessity for the enrollee. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the services at issue is included in the global surgery 
payment for the procedure (64493) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the services at issue have not been met. Therefore, we decided that 
the Plan does not have to pay for bupivacaine provided on January 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87491, 87640, 87563, 87653, 87798, 
87641, and 87500 for date of service July 24, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87491, 87640, 87563, 87653, 87798, 87641, and 87500. 
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. 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, 87491, 87640, 
87563, 87653, 87798, 87641, and 87500 for date of service July 24, 2023.